Transcranial Magnetic Stimulation (TMS) is an increasingly popular treatment for individuals with treatment-resistant depression and other psychiatric conditions. As with all clinical practices, detailed and accurate documentation of TMS sessions is essential for patient care, continuity, and compliance with medical and insurance standards.

In this article, you’ll learn how to craft clear, compliant, and effective TMS notes, incorporating best practices and templates to streamline your clinical documentation effort. Let’s dive into the key components and examples for your TMS documentation.

Disclaimer: The information provided here is for informational purposes only. It does not replace formal clinical training or legal advice. Always adhere to local laws, insurance requirements, and institutional policies related to TMS clinical documentation.

Why Proper TMS Documentation Matters

Proper TMS session recordings serve several critical purposes:

• Quality Care: Enables accurate tracking of patient response, side effects, and progress throughout treatment.

• Insurance Compliance: Demonstrates medical necessity and adherence to guidelines required by payers, such as Medicare or private insurance carriers.

• Legal and Ethical Obligations: Ensures patient safety, informed consent, and provider accountability.

• Continuity of Care: Provides a clear record for other healthcare providers involved in the patient’s treatment.

Essential Elements of a TMS Clinical Note

Typically structured similarly to a SOAP note, your TMS documentation should include:

• Patient History and Indication

• Treatment Protocol Details

• Progress Tracking (Patient Response)

• Side Effects and Adverse Events

• Plan and Follow-Up

• Patient Education and Informed Consent

• Compliance and Documentation Accuracy

Now, let’s review each of these sections in detail and provide clear examples.

1. Patient History and Indication

Initially, clearly document the patient’s:

• Diagnosis: (e.g., Major Depressive Disorder [MDD], severe, recurrent)

• Severity and Baseline Rating Scale Scores: (e.g., PHQ-9/HAM-D baseline scores.)

• History of Treatment Resistance: (List previous therapies/medications tried and failed.)

• Contraindications & Informed Consent: (Confirm patient eligibility, absence of contraindications [e.g., seizures, metal implants], and signed consent.)

Example:
"34-year-old female with severe, recurrent Major Depressive Disorder, PHQ-9 baseline score of 22. History reveals inadequate response to trials of sertraline, venlafaxine, and bupropion adjunctive therapy. No seizure history or metal implants. Informed consent obtained and on file."

2. Treatment Protocol Details

Ensure every session note includes specific technical parameters:

• Session Number/Date: e.g., “Session 10/36, Date: 2025-04-15”

• Device & Target: Specify FDA-approved device, target site (e.g., left DLPFC).

• Stimulation Parameters: Motor threshold, intensity (%MT), frequency, pulses per session, duration.

• Technician & Supervision: Clearly note who administered therapy and supervising clinician.

Example:
"Session 10/36 – FDA-approved NeuroStar device; targeted left DLPFC. Parameters: Motor threshold=58%; intensity 120% MT; frequency=10 Hz; pulse protocol=4-sec trains/26-sec intervals; total pulses=3,000; duration~20 minutes. Administered by technician J. Doe, RN under supervision of Dr. Smith, MD (on-site)."

3. Progress Tracking (Patient Response)

Evaluate and document patient progress at every session:

• Subjective Reports: Patient-reported improvements or challenges since last visit.

• Objective Assessment: Mental status, behavior observations, noted changes.

• Standardized Scales: Record periodic validated ratings (PHQ-9, HAM-D).

• Overall Progress Summary: Clearly summarize improvement or lack thereof.

Example:
"Subjective: Patient reports improved mood (rating 5/10 vs. 3/10 previously), energy and sleep improved (6–7 hours/night). Objective: Brighter affect and improved interaction. PHQ-9 today=12, reduced from baseline of 22 (~45% improvement at session 10). No suicidal ideation or acute issues."

4. Side Effects and Adverse Events

Consistently inquire and document:

• Common Side Effects: Headaches, scalp discomfort, twitching, dizziness.

• Severity and Management: Treatment paused, adjusted parameters, or provided medications.

• Rare Serious Events: Clearly document serious reactions or adverse events.

Example:
"Side Effects: Patient reports mild headache post-session yesterday (pain 3/10), managed effectively with acetaminophen. No scalp discomfort or other issues today. Tolerance: Good."

5. Plan and Follow-Up

Clearly state the ongoing course of action:

• Next Treatment Steps: Continue as planned or adjust parameters.

• Monitoring and Reevaluation: Planned use of rating scales and clinical reassessments.

• Concurrent Treatments: Medication management, psychotherapy, or supportive interventions.

• Safety Instructions: Crisis contacts provided if applicable.

Example:
"Plan: Continue TMS treatment per protocol (sessions 11–36 remaining). Will reassess PHQ-9 in five sessions. Continue sertraline 100mg daily and weekly psychotherapy. Patient provided emergency contacts and instructed to report worsening mood or side effects immediately."

6. Patient Education and Informed Consent

Document educational efforts, including:

• Importance of adherence to sessions.

• Reminders about gradual improvement.

• Reinforcement on reporting side effects.

Example:
"Education: Reinforced importance of adherence to scheduled TMS sessions and reporting side effects promptly. Explained that improvement typically emerges gradually. Patient verbalized understanding."

Compliance, Confidentiality, and Documentation Accuracy Tips

Maintain adherence to compliance best practices:

• Clearly indicate patient identification, session date, and provider signatures.

• Use structured templates or EMR fields to enhance clarity.

• Ensure medical necessity is supported with evidence-based scales and documentation details.

• Maintain privacy (following HIPAA standards) and secure storage of documentation.

Example: Comprehensive TMS Session Note Template

Here’s a concise and comprehensive TMS progress note, perfect for mid-course documentation:

Patient: Jane Doe, DOB: 01-01-1990
Session: 15 of 30, Date: 2025-05-10

Subjective: Reports “better mood overall,” improved sleep (7 hours, previously 5). Energy and motivation increased. No new symptoms.

Objective: Brighter affect, improved eye contact. PHQ-9 today = 10 (down from 18 at baseline). No suicidal ideation.

Treatment: NeuroStar FDA-approved device targeting left DLPFC; Intensity=120% MT (54%), 10Hz, 3,000 pulses total. Delivered by technician S. Jones, RN, Dr. Green supervising on-site.

Side Effects: Denies headache or scalp discomfort. Tolerating well.

Assessment: Good partial response (~44% improvement from baseline); meets continued criteria for TMS.

Plan: Continue current TMS regimen; reevaluate with PHQ-9 after five more sessions. Maintain concurrent sertraline and weekly therapy. Emergency contacts reinforced.

Patient Education: Discussed adherence importance and gradual recovery expectations. Patient understands, no concerns voiced.

Provider: Emily Green, MD, Psychiatrist - Signature on file.

Conclusion

Proper TMS clinical documentation is a cornerstone of effective, compliant, and patient-centered psychiatric care. By following structured note templates, consistently capturing essential details, and leveraging standardized outcome measures, providers can confidently meet both ethical obligations and insurance requirements, ensuring quality treatment outcomes.