Download Electroconvulsive Therapy Treatment Record (with consent and

ECT Treatment Record
Booklet
Patient Label
Calderdale Royal Hospital
Tel: 01422 357171 / 4046
Fieldhead
Tel: 01924 327439
Service User Informal. Please tick as applicable.
(applies to over 18 years unless otherwise indicated)
1
2
3
4
Service User consented, Trust consent form completed.
Service User lacks capacity to consent, DOH Form 4 completed.
Service User is under 18, with capacity, and is consenting, Form T5 completed
Service User is under 18 and lacks capacity to consent, Form T6 completed
Service user detained under the Mental Health Act 1983
5 Service User consented, Form T4 completed
6 Service User lacks capacity to consent, Form T6 completed
7 Service User lacks capacity to consent, emergency treatment under S62 required.
8 Service User is under 18 with capacity and is consenting, Form T5
9 Service User is under 18 and lacks capacity to consent, Form T6
Contents
Section 1 - to be completed by the referring medical team
 Consent Form 1. Statement of Consultant Psychiatrist /AC - to be completed for all service users
 Consent Form 2. Statement of Service User. - to be completed in addition to the above for
consenting service users
 Assessment of Capacity -for completion prior to first treatment for all service users.
 Statement of capacity - for completion prior to each treatment for service users lacking capacity
The Consent Forms and Capacity forms must be completed by the Consultant Psychiatrist/AC
 Pathway to consent, capacity, Mental Health Act
 Patient details
 Pre ECT physical examination
The patient details and pre ECT physical examination for completion by referring medical team
Section 2 - to be completed by the treating psychiatrist, anaesthetist and nursing staff
 ASA grading
 Pre ECT checklist
 ECT prescription and treatment record
 ECT post treatment nursing observations
 Abbreviated mental test / orientation score
 Checklist prior to patient leaving the treatment unit
Section 3 - to be completed by the referring Consultant Psychiatrist/AC
 Leave patient & Day Case ECT documents
To be completed for all patients leaving hospital within the 24 hour period after ECT
South West Yorkshire Partnership NHS Foundation Trust
Treatment Record Booklet
1
Record of Discussion / Service User
Consent for Electroconvulsive Therapy
Under General Anaesthesia
Service user details (or pre printed label)
Service user’s surname/family name
Service user’s given names
Date of Birth
NHS number (or other identifier)
Male
Female
Special requirements (eg other language / other
communication method___________________
Statement of Consultant Psychiatrist / Approved Clinician (please tick appropriate box below)
I have explained the procedure to the Service user.
I have provided an ECT and Anaesthesia information leaflet to the service user.
I have attempted to explain the procedure to the Service user.
I have provided the DoH & CQC patient information leaflets for detained patients.
If applicable, explanation of DoH &CQC leaflets will be revisited as soon as appropriate to do so.
In particular I have explained:
- The intended benefits_________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
- The significant, unavoidable or frequently occurring risks, including the possibility of:
-working and autobiographical memory / cognitive disturbances, headache, muscle aches, nausea, temporary confusion, dental
damage
This prescription is within N.I.C.E. guidelines YES
NO
If no, the reason for the exception is____________________________________________________________
_________________________________________________________________________________________
I have informed the patient that this prescription falls outside of the NICE guidance and the reasons why I am prescribing it.
YES
NO
N/A
I have discussed the different ways that ECT may be given and have agreed that the treatment will be started as
bilateral
right unilateral
Other…………….. ………………………………….
I have also discussed and recorded what the procedure is likely to involve, the benefits and risks of ECT and of any alternative
treatment (including no treatment) and any particular concerns of this service user.
I have informed the service user that:
 this treatment will involve anaesthesia
 people with certain medical problems can be a higher risk than those who are fit and well
 the anaesthetist will discuss the risks involved with anaesthesia and any additional procedures that may become
necessary
After assessment I believe that this patient has the capacity to give valid consent to receive ECT
After enquiry I am satisfied that there is not an Advance Decision refusing ECT.
(Tick if applicable)
(Tick if applicable)
Signed (Consultant Psychiatrist/ Approved Clinician in charge of treatment)______________________________
Name (print)_________________________________________ Date___________________________________
Statement of translator (if appropriate)
I have translated the information above to the best of my ability and in a way in which I believe s/he can understand.
Signed _________________________ Name (print)_____________________________ Date________________
Copy of this page accepted by service user. Yes / No
South West Yorkshire Partnership NHS Foundation Trust
Treatment Record Booklet
ECT Form 1
2
Record of Discussion / Service User
Consent for Electroconvulsive Therapy
Under General Anaesthesia
Service user details (or pre printed label)
Service user’s surname/family name
Service user’s given names
Date of Birth
NHS number (or other identifier)
Male
Female
Special requirements (eg other language / other
communication method___________________
Statement of Service User
Please read this form carefully. Before you sign this form, your doctor must have discussed the treatment with you, including the
benefits and risks associated with it. You should have been given written information about ECT and general anaesthesia, if not
you will be offered copies now. If you have any further questions, do ask
– we are here to
help you. You have the right to
communication
method___________________
withdraw your consent at any time.
I agree to a course of up to 12 ECT treatments under general anaesthesia.
I understand that you cannot give me a guarantee that a particular doctor will perform the procedure. The doctor will however,
have appropriate experience.
I understand that I will have the opportunity to discuss details of anaesthesia with an anaesthetist before the procedure.
I understand that it may be necessary to alter the laterality of the treatment during the course, and that my doctor will discuss this
change with me if it becomes necessary to do so.
I understand that any procedure in addition to those described on this form will be carried out only if it is necessary to save my
life or to prevent serious harm to my health.
I confirm that I have not made an Advance Decision refusing ECT.
I have been told about additional procedures that may become necessary during my treatment. I have listed below any procedure
that I do not wish to be carried out (including change of laterality).
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Service User’s Signature ________________________
Date ______________Name (print)_____________________
Consultant Psychiatrist / Approved Clinician in charge of treatment
Signature ___________________________________ Date_____________ Name (print)______________________
A witness should sign below if the service user is unable to sign but has indicated his or her consent. The doctor
signing the form must record in the clinical notes the reason why this service user is unable to sign the form.
Witness Signature_____________________________
atient Patient has withdrawn his/her consent.
Signature of patient __________________________
Name of patient (print)________________________
Date ___________ Name (print)_______________________
Date____________________
Signature of witness (nurse/doctor)_________________
Name of witness (print)__________________________
Copy of this page accepted by service user. Yes / No
South West Yorkshire Partnership NHS Foundation Trust
Treatment Record Booklet
ECT Form 2
3
Section 1
Guidance notes on the Assessment of Capacity
1
Starting from a presumption of Capacity are there reasons to believe that the person has an
impairment of, or disturbance in, the functioning of the person’s mind or brain.
( Eg because of a disability, condition or trauma).
This may be because of the person’s behaviour, circumstances or because of
Concerns expressed by someone else: please indicate
2
What is the decision that needs to be made?
Consider how much information needs to be provided and in what way. Is help needed with
specific cognitive problems?
Is advice about how to communicate needed? ( Eg family, friends, interpreter, makaton,
signer, speech and language therapist )
Are there any cultural, ethnic or religious factors which need to be considered?
Could the use of technology be helpful?
Are there circumstances that may help the person make the decision? Eg feeling at ease,
location, presence of a friend/relative.
Does the person understand what the likely consequences are?
Have alternatives been explored and explained?
Does the person understand the effects of deciding one way or another or not
deciding? Does the person understand the risks/benefits of the decision?
Does the person understand the reasons why the decision is needed?
If capacity is variable does the person understand what effect this in itself, will have on their
decision? Can the decision wait until the person has capacity?
3
The person will need to retain the information long enough to weigh it in the balance and
communicate the decision.
Are there any tools which can help the person to retain the information long to enough to
make a decision, Eg notebooks, photographs, posters, videos, voice recordings etc?
4
Does the person have the ability to use, interpret and assess the information whilst
considering the decision?
Does the person believe the information relevant to the decision in order to be able to weigh
it in the balance?
Consider the nature of the impairment or disturbance from which the person suffers, does
this affect his ability to use the information about the decision?
5
Consider how the person communicates Eg talking, signing, behaviour or by any other
means. Can anyone else such as family or friends assist in helping the person to
communicate?
An ability to communicate articulately is not in itself the defining factor in relation to capacity.
6
Details of those consulted, their relationship to the person and their views on the person’s
capacity.
7
On the balance of probabilities, is the outcome of the assessment that the person has
capacity to make the decision?
Record rationale, weighing all the evidence in the balance.
8
The IMCA must be instructed where a person lacks capacity, is unbefriended (Eg with no
Family or friends who are available and appropriate to support and/or represent him) and in
the decision about providing serious medical treatment.
South West Yorkshire Partnership NHS Foundation Trust
Treatment Record Booklet
4
Initial Record of Assessment of Capacity for Electroconvulsive Therapy
Name_________________________ Date_______________
RIO ref_________________
Guidance Notes: This assessment must be completed for all patients starting ECT without exception.
1. Once this initial assessment of capacity is completed, for those considered to have the capacity to
consent, then both pages (pages 2 & 3) of the consent form require completion. This form should be
readdressed should any changes in capacity be questioned.
2. For those considered to lack capacity at the point of initial assessment complete the first page of the
consent form (page 2) then ongoing capacity must be reassessed in the 24 hours prior to the first and
each subsequent treatment being administered and recorded on the following pages. If a person
regains capacity reassess and complete box 13 and both pages of the consent forms require
completion. (Pages 2&3).
If this is not done we will be unable to administer the treatment. This assessment must be completed only
by the Approved Clinician / Consultant Psychiatrist in charge of treatment in line with the Mental Capacity
Act 2005 s(2)+(3) (for service users over the age of 18yrs)
1
Is there an impairment of, or disturbance in, the functioning of the person’s mind.
or brain ( Eg because of a disability, condition or trauma).
Yes
If YES is this
Permanent
Temporary
Yes
No
If temporary, can the decision to treat be delayed
2
No
Understanding information about the decision to be made and helping the person make a decision.
3 & 4 Retaining information and weighing the information in the balance.
5
Communicating the decision.
6
Consultation with others.
7
Formulation of outcome
8
Involvement of the Independent Mental Capacity Advocate.
Yes
No
Name:
AC/Consultant Psychiatrist in charge of the treatment that has carried out the above assessment.
Signature____________________________ Print Name ________________________
South West Yorkshire Partnership NHS Foundation Trust
Treatment Record Booklet
Date___________
5
If reasons stated in initial assessment change please complete a new Capacity
Assessment form.
Prior to Treatment 1 I have assessed the capacity of the above named service user and confirm that
Date
he/she continues to lack capacity to consent to Electroconvulsive Therapy. The reasons remain
unchanged from the initial assessment. ( It is not necessary to complete this box if initial
assessment is within the 24 hours prior to the first treatment )
I confirm that I am the AC/Consultant Psychiatrist in charge of the treatment.
Signature
……………………………………………………
Print Name
…………………………………………………….
If service user regains capacity please complete box 13
Prior to Treatment 2 I have assessed the capacity of the above named service user and confirm that
Date
he/she continues to lack capacity to consent to Electroconvulsive Therapy. The reasons remain
unchanged from the initial assessment.
I confirm that I am the AC/Consultant Psychiatrist in charge of the treatment.
Signature
……………………………………………………
Print Name
…………………………………………………….
If service user regains capacity please complete box 13
Prior to Treatment 3
I have assessed the capacity of the above named service user and confirm that
he/she continues to lack capacity to consent to Electroconvulsive Therapy. The reasons remain
unchanged from the initial assessment.
I confirm that I am the AC/Consultant Psychiatrist in charge of the treatment.
Signature
……………………………………………………
Print Name
…………………………………………………….
Date
If service user regains capacity please complete box 13
Prior to Treatment 4 I have assessed the capacity of the above named service user and confirm that
Date
he/she continues to lack capacity to consent to Electroconvulsive Therapy. The reasons remain
unchanged from the initial assessment.
I confirm that I am the AC/Consultant Psychiatrist in charge of the treatment.
Signature
……………………………………………………
Print Name
…………………………………………………….
If service user regains capacity please complete box 13
Date
Prior to Treatment 5 I have assessed the capacity of the above named service user and confirm that
he/she continues to lack capacity to consent to Electroconvulsive Therapy. The reasons remain
unchanged from the initial assessment.
I confirm that I am the AC/Consultant Psychiatrist in charge of the treatment.
Signature
……………………………………………………
Print Name
…………………………………………………….
If service user regains capacity please complete box 13
Prior to Treatment 6 I have assessed the capacity of the above named service user and confirm that
Date
he/she continues to lack capacity to consent to Electroconvulsive Therapy. The reasons remain
unchanged from the initial assessment.
I confirm that I am the AC/Consultant Psychiatrist in charge of the treatment.
Signature
……………………………………………………
Print Name
…………………………………………………….
If service user regains capacity please complete box 13
Prior to Treatment 7 I have assessed the capacity of the above named service user and confirm that
Date
he/she continues to lack capacity to consent to Electroconvulsive Therapy. The reasons remain
unchanged from the initial assessment.
I confirm that I am the AC/Consultant Psychiatrist in charge of the treatment.
Signature
……………………………………………………
Print Name
…………………………………………………….
If service user regains capacity please complete box 13
South West Yorkshire Partnership NHS Foundation Trust
Treatment Record Booklet
6
Prior to Treatment 8 I have assessed the capacity of the above named service user and
Date
confirm that he/she continues to lack capacity to consent to Electroconvulsive Therapy. The
reasons remain unchanged from the initial assessment.
I confirm that I am the AC/Consultant Psychiatrist in charge of the treatment.
Signature
……………………………………………………
Print Name
…………………………………………………….
If service user regains capacity please complete box 13
Prior to Treatment 9 I have assessed the capacity of the above named service user and
Date
confirm that he/she continues to lack capacity to consent to Electroconvulsive Therapy. The
reasons remain unchanged from the initial assessment.
I confirm that I am the AC/Consultant Psychiatrist in charge of the treatment.
Signature
……………………………………………………
Print Name
…………………………………………………….
If service user regains capacity please complete box 13
Prior to Treatment 10 I have assessed the capacity of the above named service user and
Date
confirm that he/she continues to lack capacity to consent to Electroconvulsive Therapy. The
reasons remain unchanged from the initial assessment.
I confirm that I am the AC/Consultant Psychiatrist in charge of the treatment.
Signature
……………………………………………………
Print Name
…………………………………………………….
If service user regains capacity please complete box 13
Prior to Treatment 11 I have assessed the capacity of the above named service user and
Date
confirm that he/she continues to lack capacity to consent to Electroconvulsive Therapy. The
reasons remain unchanged from the initial assessment.
I confirm that I am the AC/Consultant Psychiatrist in charge of the treatment.
Signature
……………………………………………………
Print Name
…………………………………………………….
If service user regains capacity please complete box 13
Prior to Treatment 12 I have assessed the capacity of the above named service user and
Date
confirm that he/she continues to lack capacity to consent to Electroconvulsive Therapy. The
reasons remain unchanged from the initial assessment.
I confirm that I am the AC/Consultant Psychiatrist in charge of the treatment.
Signature
……………………………………………………
Print Name
…………………………………………………….
If service user regains capacity please complete box 13
Date
Service User has regained Capacity to consent to Electroconvulsive
Therapy.
13 I have assessed the capacity of the above named service user and confirm that he/she has
capacity to consent to Electroconvulsive Therapy.
Consent has been given by the service user for Electroconvulsive Therapy and the consent form
(and form T4 for detained patients) is completed.
I confirm that I am the AC/Consultant Psychiatrist in charge of the treatment.
Signature
………………………………………………………….
Print Name
…………………………………………………….
South West Yorkshire Partnership NHS Foundation Trust
Treatment Record Booklet
7
Pathway to ECT – Informal patients
This flow chart is based on the assumption that the approved clinician in charge of
the patient’s care has decided that the ECT is the most appropriate treatment for the
patient in question, and that they are over 18 years of age.
Patient has
capacity
Consenting
AC
completes
Trust
consent
form
Patient lacks
capacity
Non
consenting
You cannot
administer
ECT
No advance decision
refusing ECT.
No authorised
attorney objecting to
ECT.
No decision from
court of protection
preventing ECT.
Is patient
Treat
Resistive
Valid & applicable
advance decision
refusing ECT.
Authorised attorney
objecting to ECT.
Decision of court of
protection preventing
ECT.
You cannot administer
ECT
Passively
accepting
KEY
Assess under
MHA.
See appropriate
pathway for
detained patient.


Treat using DoH
Form 4
Capacity must be now
assessed prior to
each treatment.
DoH – Department of
Health
AC – Approved Clinician
in charge of patient’s care
MHA –Mental Health Act
If patient regains
capacity the
appropriate pathway
must be followed.
CQC – Care Quality
Commission
SOAD – second opinion
appointer doctor
UNDER 18 YEARS OF AGE
If informal, lacking capacity but passively accepting of
treatment contact CQC for a SOAD to assess and if
considered appropriate to complete Form T6.
If informal, with capacity and consenting to treatment
contact CQC for a SOAD to assess and if considered
appropriate, to complete Form T5.
South West Yorkshire Partnership NHS Foundation Trust
Treatment Record Booklet
8
Pathways to ECT – Detained patients
This flow chart is based on the assumption that the approved clinician in charge of the
patient’s care has decided that ECT is the most appropriate treatment for the patient in
question, and that they are over 18 years of age.
Patient has
capacity
Consenting
AC
completes
Form T4
Treat
Patient lacks
capacity
Non
Consenting
You cannot
administer ECT
except under
S62 (and only in
the absence of
an Advance
decision)
UNDER 18 YEARS OF AGE
No Advance decision
refusing ECT.
No authorised attorney
objecting to ECT.
No decision from court
of protection preventing
ECT.
Valid & applicable
Advance Decision
refusing ECT.
Authorised attorney
objecting to ECT.
Decision of court of
protection preventing
ECT.
Treat using S62 if
urgent treatment.
SEEK ADVICE
You cannot
administer ECT
unless S62a&b apply.
Inform CQC need for
SOAD to assess and if
appropriate complete
T6.
If detained, under18 with
capacity and consenting contact
must be made with CQC for a
SOAD to assess and if
considered appropriate must
complete Form T5
Treat.
Capacity must now be
assessed prior to each
treatment
If detained, under18 and lacks
capacity to consent contact must
be made with CQC for a SOAD
to assess and if considered
appropriate must complete Form
T6
If patient regains
capacity the appropriate
pathway must be
followed.
South West Yorkshire Partnership NHS Foundation Trust
Treatment Record Booklet
Key
CQC – Care Quality
Commission
SOAD – Second
Opinion Appointed
Doctor.
AC – Approved
Clinician in charge of
patients care
9
Patient details
Ethnicity code (Please
circle)
White
British A /Irish B / Other C
Mixed
White& Black Caribbean D
White & Black African E
White & Asian F /Other G
Responsible adult/ Next of kin contact details
Asian or Asian British
Indian H /Pakistani J/
Bangladeshi K /other L
Black or Black British
Carribbean M
African N/ Other P
Consultant Psychiatrist
Other Ethnic Groups
Chinese R/Other S
Not stated- Z
Diagnosis
Reason why ECT is being used to treat this condition
Previous ECT
Has the patient received ECT
before?
If yes, date of last course and comments
Yes
No
Notification to the ECT clinic by the assessing doctor should be completed within 48 hours of the
time of the 1st anticipated treatment, and not later than 24 hours. Emergencies excepted.
Yes
No
1. Day case ECT discussed with Lead ECT Clinician?
2. ECT clinic notified of patient details (preferably within 48 hours)?
3. Provision to ensure case notes are available to ECT clinic staff?
4. Provision to ensure results of investigations available to clinic staff?
5. Arrangements made for clinical review between each treatment?
6. Consent completed and relevant copy filed in case notes?
7. Responsible adult identified (Day case patient’s only)?
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Treatment Record Booklet
10
Medication at the start of treatment (please specify drug dose and date commenced)
Approved name (CAPITALS please)
Dose
Date commenced
(if known)
Consider seizure
1
threshold
2
3
4
5
Possible interactions with
6
anaesthetic agents
7
8
9
10
Medicine card must
Recently discontinued medications /substance
accompany notes to ECT
Approved name (CAPITALS please)
Dose
Date stopped
department
Allergies & Adverse Reactions (including details of reaction)
Circle and fill in
Non smoker
Current smoker
Ex-smoker
Alcohol
......./day for ......years
date stopped...........................
reason stopped........................................................
................units/week
Other.......................................................................
Driving status.....................................................
Surgical/medical history:
Has the patient had any anaesthetic or surgical complications?
A patient with a history of problems with anaesthesia must be referred to the anaesthetist
South West Yorkshire Partnership NHS Foundation Trust
Treatment Record Booklet
11
No
Yes/mild
Yes severe/unstable
Chest pain on exercise or in bed?
Short of breath on light exercise or at rest?
Wheezing or coughing up phlegm?
High blood pressure or palpitations?
Epilepsy/fits/faints?
Heartburn?
Arthritis/muscle/neurological disease?
Any history of abnormal bleeding or bruising?
If yes, do clotting screen
Any patients with entries in severe/unstable column must be referred to the anaesthetist
Yes
Not known
HIV POSITIVE?
Hep B/C positive?
Patients with a history of jaundice or IV drug use should be screened in line with Trust policy
For patients of child bearing potential please perform a pregnancy test.
Positive
Negative
Refused
Test result
Pregnancy may be a contraindication to ECT, refer to anaesthetist and discuss at consultant level
Any other significant history
Item
Dental check/oral examination performed?
Dentures?
Crowned/bridged teeth?
Loose teeth?
Pacemaker?
Contact lenses?
Hearing aid?
Body piercing?
All patients must have risk of dental damage explained
Yes
No
Details
Date Done
Yes
No
Comments
Chest x-ray (if clinically indicated)?
ECG (>45yrs or clinically indicated)?
FBC?
U&Es?
Sickle-cell test?
Other (state)?
Black, Middle Eastern, Asian and Eastern Mediterranean patients must be sickle cell tested
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Treatment Record Booklet
12
Pulse rate
……………
If <50 or >100 or irregular get ECG and refer
Blood pressure
refer
……………
If systolic >160 and/or diastolic >100 get ECG and
to the anaesthetist
……………
Temperature
Patients with T>38° not usually fit for ECT and
should be
discussed at consultant level
Weight
…….Kg
Height ……….m
BMI (W/H2) ……
BMI >35 or weight >130Kg must be referred to anaesthetist
Auscultation of chest …………………………………
Patients with any significant abnormality other than mild change should be referred after
chest X ray
Heart sounds ……………………………..................
Any patient with a murmur and cardiac symptoms must be referred to the anaesthetist.
Investigations
All patients should have FBC and U & Es within 14 days prior to treatment. If abnormal, the investigations
should be repeated prior to ECT. If still abnormal – refer to the anaesthetist.
Latest blood results
Hb …………….. WBC ………… Platelets …………. Na ………… K…….. Urea ……….
All patients over the age of 45 years or if clinically indicated must have an ECG within the last 14 days, and
any abnormality be referred to the anaesthetist.
General comments
Signature of doctor: _________________________
Print name
_________________________
Date of examination. ___ /__ /___
Physical examination prior to ECT (must have been undertaken within 14 days of the
commencement o treatment)
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Treatment Record Booklet
13
Please attach
ECG
recording to this
page
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Treatment Record Booklet
14
Section 2
Anaesthetic assessment (Anaesthetist to complete)
General comments
Recent 12 Lead ECG available
Yes
No
ASA GRADINGS
Asa Grade 1
Normal healthy individual
Asa Grade 2
Mild systemic disease that does not limit activity
Asa Grade 3
Severe systemic disease that limits activity but is not incapacitating
Asa Grade 4
Incapacitating systemic disease which is constantly life threatening
Asa Grade 5
Moribund, not expected to survive 24 hours with or without surgery.
STATEMENT OF ANAESTHETIST
I have discussed the anaesthetic part of the procedure with the patient. I have provided information, if appropriate,
that is not included in the information booklet, and I have answered any questions the patient has asked.
I have assessed this patient to have an ASA grading of:
ASA 1
ASA 2
ASA 3
ASA 4
ASA 5
Signed______________________
Print___________________
Date ___________
Changes to ASA grading during the course of treatment
From ASA grade_____
to ASA grade_____
Signed___________________________
Name(print) __________________________
Date ____________________________
Comments
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Treatment Record Booklet
15
ECT NURSING CHECKLIST -To be completed by ward staff
1
2
3
Treatment no.& date
4
5
6
4
5
6
BP
Pulse
Temperature
O2 saturation on ward if
pulsoxymeter available
Blood glucose level (BM) if
diabetic
Fasted from ( solids)
Fasted from ( fluids)
Visited toilet
Case notes / medicine card
Consent forms present
MHA documents present
(If applicable)
Wristband
Completed by (initial)
ECT NURSING CHECKLIST -To be completed by ECT clinic staff
1
2
3
Date
I.D. confirmed
Case notes, medicine card,
consent/ mha forms
Fasted from ( solids)
Fasted from ( fluids)
Anaesthetist informed of any
abnormalities
Dental state /
Dentures removed
Hearing aids/ other
prosthesis. Removed?
Lenses/ glasses removed
Laterality
Possibility of pregnancy
(if applicable)
Permission for an observer
Presentation concurs with
initial consent status
Presentation concurs with
initial capacity assessment
Any questions/info
Completed by (initial)
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Treatment Record Booklet
16
ECT NURSING CHECKLIST -To be completed by ward staff
7
8
9
Treatment no.& date
10
11
ECT NURSING CHECKLIST -To be completed by ECT clinic staff
7
8
9
10
Date
11
12
BP
Pulse
Temperature
O2 saturation on ward if
pulsoxymeter available
Blood glucose level (BM) if
diabetic
Fasted from ( solids)
Fasted from ( fluids)
Visited toilet
Case notes / medicine card
Consent forms present
MHA documents present
(If applicable)
Wristband
Completed by (initial)
12
I.D. confirmed
Case notes, medicine card,
consent/ mha forms
Fasted from ( solids)
Fasted from ( fluids)
Anaesthetist informed of any
abnormalities
Dental state /
Dentures removed
Hearing aids/ other
prosthesis. Removed?
Lenses/ glasses removed
Laterality
Possibility of pregnancy
(if applicable)
Permission for an observer
Presentation concurs with
initial consent status
Presentation concurs with
initial capacity assessment
Any questions/info
Completed by (initial)
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Treatment Record Booklet
17
Strength of seizure rating
Strength : 0= Absent
1
/
/
2
/
/
3
/
/
4
/
/
5
/
/
6
/
/
7
/
/
8
/
/
9
/
/
10
/
/
11
/
/
12
/
/
Bilateral (BL)
Stimulus
Electrode
position
Treatment
No./Date
Time out
/ Sign out
Type:
Sign in
Seizure
Generalrating
notes scale
Unilateral (UL)
1=Mild
Visual.
Seizure duration,
type and strength.
Partial (PTL)
2=Moderate
EEG
duration
3= Strong
Comments /
plan for next
session.
Signature
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
General notes
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Allergy status………………………………..
Difficult airway/Aspiration risk/Known hiatus hernia Y/N
ASA grade………
Name & Signature………………………………………..
Date
Pre treatment
…………
observations
IVI Induction Relaxant Other
drugs/
fluids
Pulse
BP
SPO²
Pulse
BP
SPO²
Pulse
BP
SPO²
Pulse
BP
SPO²
Pulse
BP
SPO²
Pulse
BP
SPO²
Pulse
BP
SPO²
Pulse
BP
SPO²
Pulse
BP
SPO²
Pulse
BP
SPO²
Pulse
BP
SPO²
Pulse
BP
SPO²
Comment /signature
Post treatment
observations
Pulse
BP
SPO²
Pulse
BP
SPO²
Pulse
BP
SPO²
Pulse
BP
SPO²
Pulse
BP
SPO²
Pulse
BP
SPO²
Pulse
BP
SPO²
Pulse
BP
SPO²
Pulse
BP
SPO²
Pulse
BP
SPO²
Pulse
BP
SPO²
Pulse
BP
SPO²
General notes
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ECT Department Nursing Notes
Date
Notes
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Print
20
ECT nursing observations - recovery
Date
Recovery
Time
Respirations
Spo2
Pulse
Blood pressure
BM’s
Temp
Date
Recovery
Time
Respirations
Spo2
Pulse
Blood pressure
BM’s
Temp
Date
Recovery
Time
Respirations
Spo2
Pulse
Blood pressure
BM’s
Temp
Date
Recovery
Time
Respirations
Spo2
Pulse
Blood pressure
BM’s
Temp
Date
Recovery
Time
Respirations
Spo2
Pulse
Blood pressure
BM’s
Temp
Date
Recovery
Time
Respirations
Spo2
Pulse
Blood pressure
BM’s
Temp
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ECT nursing observations - recovery
Date
Recovery
Time
Respirations
Spo2
Pulse
Blood pressure
BM’s
Temp
Date
Recovery
Time
Respirations
Spo2
Pulse
Blood pressure
BM’s
Temp
Date
Recovery
Time
Respirations
Spo2
Pulse
Blood pressure
BM’s
Temp
Date
Recovery
Time
Respirations
Spo2
Pulse
Blood pressure
BM’s
Temp
Date
Recovery
Time
Respirations
Spo2
Pulse
Blood pressure
BM’s
Temp
Date
Recovery
Time
Respirations
Spo2
Pulse
Blood pressure
BM’s
Temp
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ECT post treatment checklist
Criteria (please complete Yes or No)
Date
Fully conscious and
alert?
*
Vital signs stable?
*
Has taken oral fluids?
*
**Time to appropriate
orientation**
(age, day, month, place
and person)
Score (out of 5)
*
mins
mins
mins
mins
mins
mins
mins
mins
mins
mins
mins
mins
---
---
---
---
---
---
---
---
---
---
---
---
Walking around safely
with no dizziness or
fainting?
*
Minimal nausea?
*
Minimal soreness or
muscle pain?
Headache?
Cannula removed and
dry dressing applied? *
Possessions/prosthesis
returned?
*
Any medication given and / or advice re prophylactic medication required prior to further treatments must
be recorded on medicine card and / or documented in the patient’s case notes
Out patients only
Has a responsible adult
to take him/her home
who has agreed to 24hour responsibilities? *
Transport home
confirmed?
*
Out patient information
provided - both verbal
and written?
*
Advice re contact in the
event of problems?
*
Anaesthetist aware of *
any abnormalities?
** Time to reorientation is to be taken from time the patient is first received in recovery**
Note * all criteria must be met before the patient leaves the department
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Section 3
Day case and leave patient information and agreement.
Because of the nature of your disorder and treatment there are some restrictions that you
need to understand and agree to.

You must not have anything to eat, or any drinks containing milk from 1 am on the day of your treatment.

After 1 am you may drink a glass of water (up to 500 mls approx) up to 3 hours before your treatment.

If you have not fasted your treatment may be cancelled for safety reasons

You will be required to remain in hospital for at least 2 hours after your treatment and will not be
allowed to proceed on your period of leave / return home until the nursing staff are satisfied that you have
recovered sufficiently from your anaesthetic

Do not leave the hospital if you are feeling unsteady or confused.

You must be escorted to and from the ECT clinic by a named responsible adult. Transport can be booked in
advance if required.

You must be directly supervised by a responsible adult for 24 hours after treatment and you must not sign
legal documents, ride a bicycle, operate dangerous machinery or appliances, travel or go out alone or
undertake any potentially hazardous tasks or activities.

You must not be left in sole charge of young children for the 24 hour period following treatment

Bring any minor ill effects of the treatment to the notice of the ECT clinic staff at the earliest opportunity,
and report any major problems to your GP/NHS Direct immediately.

Do not bring valuable items with you because the Trust cannot accept responsibility for their loss.

Please ensure that you have received and read the booklets provided for you which give more detailed
information about your treatment, please pay special attention to the section relating to day case treatment
In addition
 You must not drive for the duration of the course of ECT unless otherwise advised by your Consultant
Psychiatrist.

You should not drink alcohol or eat foods containing alcohol for the 24 hour period following each treatment
Part A
Patient agreement
I have read, understood and agree to the above requirements.
Signed ______________________
Print name __________________
Date___________
Part B Doctor’s statement
I confirm that I have explained to the patient the above requirements for patients returning home within 24 hours
of having ECT treatment. I have also provided the Trust information leaflet in relation to ECT and anaesthesia
Signed ______________________ Print name________________ Date____________
If you are unable to attend for an ECT treatment contact:
______________________________
Once you have returned home if you begin to feel unwell contact:______________________________
Please offer a copy of this page to the service user and responsible adult
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Responsible adult agreement to the provision of care for 24 hours after ECT.
Following discussion with the doctor I have agreed to act as the adult responsible for:Patient’s name
The procedure involves a short general anaesthetic which can produce side effects lasting for
several hours. It is therefore important to confirm that:
1. I have received an explanation from the doctor of the likely care needed following the
procedure.
2. I have received an explanation of the likely effects of the procedure.
3. I understand the explanation that I have received.
4. I have received information and advice about whom I should contact in the event that I
have concerns, or require support.
5. I agree and am willing to be responsible for the above named for a period of 24 hours after
each ECT treatment.
Part A
Responsible adult
Signed ___________________________ Print name ___________________ Date __________
Part B
Doctor’s statement
I confirm that I have provided the responsible adult with the above information for day case ECT;
and have offered a copy of this page. I have also provided the Trust information leaflet in relation
to ECT and anaesthesia together with contact details for support and advice.
Signed ___________________________ Print name ___________________ Date __________
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OUTPATIENT ECT CARE PLAN
SERVICE USER NAME:
CARER’S NAME (responsible adult):
NAME/S OF HEALTH CARE WORKER/S PROVIDING CARE:
DATE:
TREATMENT AND CLINICAL REVIEW DATES
1st
treatment
1st
Review
4th
treatment
4th
Review
7th
treatment
7th
Review
10th
treatment
10th
Review
2nd
treatment
2nd
Review
5th
treatment
5th
Review
8th
treatment
8th
Review
11th
treatment
11th
Review
3rd
treatment
3rd
Review
6th
treatment
6th
Review
9th
treatment
9th
Review
12th
treatment
12th
Review
PLANNED HOME VISITS AND INTERVENTIONS REQUIRED
In case of mental health or ECT/anaesthesia related concerns, contact your care team on the
following telephone number/s:
Out of hours (5pm – 9am Monday to Friday, and weekends anytime) contact:
Other relevant information
It is important that the person acting as responsible adult is aware of these contact details.
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Appendix 1
Guidance to health professionals
(to be read in conjunction with consent policy)
What a consent form is for
A consent form documents the patient’s agreement to go ahead with the treatment proposed by
the Approved Clinician/Consultant Psychiatrist in charge of the patients care.
It is not a legal waiver – if patients, for example, do not receive enough information on which to
base their decision, or have been pressurised into the decision, then the consent may not be valid,
even though the form has been signed. Patients are also entitled to change their mind after
signing the form, if they retain capacity to do so. The form should act as an aide-memoire to
health professionals and patients, by providing a checklist of the kind of information patients
should be offered, and by enabling the patient to have a written record of the main points
discussed. In no way, however, should the written information provided for the patient be regarded
as a substitute for face-to-face discussions with the patient.
Information
Information about what the treatment will involve, its benefits and risks (including side-effects and
complications) and the alternatives to the particular procedure proposed, is crucial for patients
when making up their minds. The courts have stated that patients should be told about ‘significant
risks which would affect the judgement of a reasonable patient’. ‘Significant’ has not been legally
defined, but the GMC requires doctors to tell patients about ‘serious or frequently occurring’ risks.
In addition if patients make clear they have particular concerns about certain kinds of risk, you
should make sure they are informed about these risks, even if they are very small or rare. You
should always answer questions honestly. Sometimes, patients may make it clear that they do not
want to have any information about the options, but want you to decide on their behalf. In such
circumstances, you should do your best to ensure that the patient receives at least very basic
information about what is proposed. Where information is refused, you should document this on
the “Statement of Consultant Psychiatrist / AC” form (ECT Form 1) and in the patient’s notes.
The law on consent
See the Department of Health’s Reference guide to consent for examination or treatment for a
comprehensive summary of the law on consent (also available at www.doh.gov.uk/consent).
Who can give consent
Everyone aged 16 or more is presumed to be competent to give consent for themselves, unless
the opposite is demonstrated.
However, in the case of ECT, all persons under 18 whether detained or informal will require an
assessment by a second opinion doctor (SOAD).
If the patient is over 18 years of age, and does not have capacity to consent, you should use the
DOH form 4 (form for adults who are unable to consent to investigation or treatment). A patient
will not be capacitous to consent if:
 he is unable to comprehend and retain information material to the decision and/or
 he is unable to weigh and use this information in coming to a decision and/or
 he is unable to believe the information provided and/or
 he is unable to communicate the decision to you.
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You should always take all reasonable steps for example involving specialist colleagues (eg
Speech and Language Therapists) to support the patient in making their own decision, before
concluding that they are unable to do so.
Relatives cannot be asked to sign this form on behalf of an adult who is not capacitous to consent
for himself or herself, however a person with appropriate authority under a Lasting Power of
Attorney or a Court appointed Deputy will be able to sign the consent form.
Any patient that lacks capacity will require an ongoing assessment of capacity prior to each
treatment in the course. This is a duty of the Consultant Psychiatrist/AC in charge of the
individual’s treatment and cannot be delegated.
How to use these forms
The record of consent consists of two forms, “Statement of Consultant Psychiatrist/AC” and
“Statement of Service User” (ECT Forms 1&2).
For consenting patients completion of both forms is required.
All patients regardless of mental health status will require the “Statement of Consultant
Psychiatrist/AC” (ECT Form 1) completing by the Consultant Psychiatrist/AC. This form is a record
of the information that has been given to the patient and it also records whether the referrer is
prescribing unilateral or/bilateral treatment.
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