TMS Treatment Session Log
| Form ID |
FRM-TMS-001 |
Revision |
1.0 |
Patient Information
| Field |
Entry |
| Patient Name |
|
| MRN |
|
| Date of Birth |
|
| Diagnosis |
☐ MDD ☐ OCD ☐ Other: _______ |
| Treatment Protocol |
☐ Standard rTMS ☐ iTBS ☐ Other: _______ |
| Prescribing Physician |
|
Session Information
| Field |
Entry |
| Date |
|
| Session Number |
____ of ____ |
| Start Time |
|
| End Time |
|
| Operator Name |
|
| Operator Credentials |
|
Pre-Treatment Assessment
Daily Safety Screening
| Question |
Response |
| Any new medications since last session? |
☐ Yes (list below) ☐ No |
| Any changes to existing medications? |
☐ Yes (list below) ☐ No |
| Did you get at least 4 hours of sleep? |
☐ Yes ☐ No |
| Any alcohol in past 24 hours? |
☐ Yes (amount: _____) ☐ No |
| Any recreational drugs? |
☐ Yes ☐ No |
| Any new medical symptoms or illness? |
☐ Yes (describe below) ☐ No |
| Any problems since last treatment? |
☐ Yes (describe below) ☐ No |
Notes on positive responses:
Vital Signs (if indicated)
| Parameter |
Value |
| Blood Pressure |
/ mmHg |
| Heart Rate |
bpm |
Treatment Parameters
Motor Threshold
| Field |
Entry |
| Motor Threshold (%) |
|
| MT Determination Date |
|
| Rechecked This Session? |
☐ Yes ☐ No |
Stimulation Parameters
| Parameter |
Prescribed |
Delivered |
| Target Site |
|
|
| Coil Type |
|
|
| Frequency (Hz) |
|
|
| Intensity (% MT) |
|
|
| Pulses per Train |
|
|
| Inter-Train Interval (sec) |
|
|
| Number of Trains |
|
|
| Total Pulses |
|
|
| Session Duration |
|
|
Coil Position
| Field |
Entry |
| Positioning Method |
☐ 5-cm Rule ☐ Neuronavigation ☐ Other |
| Coil Position Verified? |
☐ Yes |
| Coil Angle |
|
| Position Markings Used? |
☐ Yes ☐ No |
Treatment Delivery
| Field |
Entry |
| Full Treatment Delivered? |
☐ Yes ☐ No |
| If No, Reason |
|
| If No, Pulses Delivered |
|
Interruptions (if any)
Patient Tolerance
During Treatment
| Symptom |
Present? |
Severity (1-10) |
Notes |
| Scalp pain/discomfort |
☐ Yes ☐ No |
|
|
| Facial twitching |
☐ Yes ☐ No |
|
|
| Neck pain |
☐ Yes ☐ No |
|
|
| Dizziness/lightheadedness |
☐ Yes ☐ No |
|
|
| Anxiety |
☐ Yes ☐ No |
|
|
| Other: |
☐ Yes ☐ No |
|
|
Comfort Measures Used:
☐ Repositioning ☐ Intensity adjustment ☐ Break taken ☐ Other: _______
Post-Treatment Assessment
| Symptom |
Present? |
Severity (1-10) |
| Headache |
☐ Yes ☐ No |
|
| Scalp tenderness |
☐ Yes ☐ No |
|
| Fatigue |
☐ Yes ☐ No |
|
| Difficulty concentrating |
☐ Yes ☐ No |
|
| Other: |
☐ Yes ☐ No |
|
Overall Tolerance Rating
☐ Excellent - No discomfort
☐ Good - Mild, tolerable discomfort
☐ Fair - Moderate discomfort requiring intervention
☐ Poor - Significant discomfort, treatment modified
☐ Intolerable - Treatment stopped early
Adverse Events
☐ No adverse events this session
| Event |
Details |
| Description |
|
| Time of Onset |
|
| Duration |
|
| Severity |
☐ Mild ☐ Moderate ☐ Severe |
| Action Taken |
|
| Resolved? |
☐ Yes ☐ No ☐ Ongoing |
| Physician Notified? |
☐ Yes ☐ No ☐ N/A |
| Physician Name/Time |
|
Adverse Event Report Filed? ☐ Yes (Report #: _____) ☐ No ☐ N/A
Clinical Observations
Patient's subjective report of symptom change:
☐ Much worse ☐ Somewhat worse ☐ No change ☐ Somewhat better ☐ Much better
Comments:
Weekly Outcome Assessment (if applicable)
| Assessment |
Score |
Date |
| PHQ-9 |
|
|
| HAM-D |
|
|
| Y-BOCS |
|
|
| Other: |
|
|
Equipment
| Field |
Entry |
| Device Model/Serial # |
|
| Coil Serial # |
|
| Equipment Functioning Normally? |
☐ Yes ☐ No |
| Issues Noted |
|
Next Session
| Field |
Entry |
| Next Appointment Date |
|
| Next Appointment Time |
|
| Parameters to Modify? |
☐ Yes (describe) ☐ No |
| MT Recheck Needed? |
☐ Yes ☐ No |
| Physician Review Needed? |
☐ Yes ☐ No |
Signatures
Operator Attestation
I certify that this treatment session was administered in accordance with the prescribed protocol and documented accurately.
| Field |
Entry |
| Operator Signature |
|
| Date |
|
| Time |
|
Supervising Physician Review (if required)
| Field |
Entry |
| Physician Signature |
|
| Date |
|
| Comments |
|
Form FRM-TMS-001 Rev 1.0 - TMS Treatment Session Log
