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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)? South West Yorkshire Partnership NHS Foundation Trust 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 South West Yorkshire Partnership NHS Foundation Trust 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) South West Yorkshire Partnership NHS Foundation Trust Treatment Record Booklet 13 Please attach ECG recording to this page South West Yorkshire Partnership NHS Foundation Trust 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 South West Yorkshire Partnership NHS Foundation Trust 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) South West Yorkshire Partnership NHS Foundation Trust 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) South West Yorkshire Partnership NHS Foundation Trust 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 South West Yorkshire Partnership NHS Foundation Trust Treatment Record Booklet 18 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 South West Yorkshire Partnership NHS Foundation Trust Treatment Record Booklet 19 ECT Department Nursing Notes Date Notes South West Yorkshire Partnership NHS Foundation Trust Treatment Record Booklet Sign 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 South West Yorkshire Partnership NHS Foundation Trust Treatment Record Booklet 21 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 South West Yorkshire Partnership NHS Foundation Trust Treatment Record Booklet 22 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 South West Yorkshire Partnership NHS Foundation Trust Treatment Record Booklet 23 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 South West Yorkshire Partnership NHS Foundation Trust Treatment Record Booklet 24 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 __________ South West Yorkshire Partnership NHS Foundation Trust Treatment Record Booklet 25 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. South West Yorkshire Partnership NHS Foundation Trust Treatment Record Booklet 26 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. South West Yorkshire Partnership NHS Foundation Trust Treatment Record Booklet 27 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. South West Yorkshire Partnership NHS Foundation Trust Treatment Record Booklet 28