Pulmonary Rehabilitation Session Note

Patient: [name, DOB/MRN per facility policy]

Date of Service: [date]

Session: [session number of planned total, e.g., "12 of 36"]

Total Session Minutes: [minutes]

Delivery Mode: [in-person outpatient / telehealth] (If telehealth, include patient and clinician locations.)

Clinician: [name and credentials]

Pre-Session Assessment

• Interval changes since last session: [exacerbations / hospitalizations / ED visits / falls / medication changes / none] (If patient cannot provide history, document source or reason unable to obtain.)
• Baseline symptoms today: [dyspnea description and Borg or program-standard rating, other symptoms if reported]
• Safety screen: [cleared / not cleared with rationale]
• Home program adherence: [adherent / partially adherent / not adherent / not prescribed] (Omit if no home program assigned.)
• Resting vitals: HR [bpm], BP [mmHg], SpO2 [%] on [oxygen device and flow / room air], baseline dyspnea/RPE [rating] (If any vital cannot be obtained, document why.)

Interventions Performed

• Aerobic training: [mode], [workload/settings], [duration in minutes], [intensity: RPE/Borg and HR if tracked], [oxygen settings during exercise] (If not performed, state reason.)
• Resistance training: [muscle groups], [sets x reps], [load/resistance] (Omit if not performed.)
• Breathing techniques / Airway clearance / IMT: [technique/device], [duration], [patient performance] (Include only if performed.)
• Education: [specific topic], [method], [patient response or teach-back result], [homework assigned] (Do not document "education provided" without specifying topic and response. Omit if not addressed.)
• Modifications from planned prescription: [modification and rationale] (Omit if none.)
• Continuous oximetry monitoring used: [yes / no]

Monitoring & Response

• During exercise: SpO2 nadir [%] with oxygen adjustments [if any], peak HR [bpm], symptoms at peak exertion [dyspnea rating, fatigue, other], rest breaks [number and duration]
• Recovery: Post-exercise HR [bpm], BP [mmHg], SpO2 [%] on [oxygen/room air], symptom resolution [description]

Adverse Events: [none / event type, objective findings, immediate actions, disposition, and follow-up plan] (Must be explicitly documented; do not leave blank.)

Assessment & Plan

Assessment: [overall session tolerance with objective support: achieved duration/workload, hemodynamic stability, SpO2 within target, symptom ratings] [progress toward ITP goals with specific evidence] [barriers if present]

Plan:

• Next session: [exercise prescription adjustments or "continue per ITP" with progression target]
• Education: [upcoming topic] (Omit if not planned.)
• Home assignment: [exercise or skill practice with frequency, duration, intensity] (Omit if not assigned.)
• Communications: [notifications to referring clinician or PR medical director regarding new symptoms, oxygen changes, repeated desaturations, lack of progress] (Omit if none needed.)

Clinician Signature: [signature with credentials, date/time]