Sync template from atomicqms-style deployment
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Forms/Recording-Logs/FRM-EEG-001-Recording-Log.md
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Forms/Recording-Logs/FRM-EEG-001-Recording-Log.md
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# EEG Recording Log
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| Form ID | FRM-EEG-001 | Revision | 1.0 |
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|---------|-------------|----------|-----|
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---
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## Patient Information
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| Field | Entry |
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|-------|-------|
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| Patient Name | |
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| MRN | |
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| Date of Birth | |
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| Age | |
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| Sex | ☐ Male ☐ Female |
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| Study Date | |
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| Study Time Start | |
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| Study Time End | |
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| Study Duration | minutes |
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---
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## Ordering Information
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| Field | Entry |
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|-------|-------|
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| Ordering Physician | |
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| Study Type | ☐ Routine EEG ☐ Sleep-Deprived EEG ☐ Ambulatory EEG ☐ Portable/Bedside ☐ Other: _______ |
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| Clinical Indication | |
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| Patient Location | ☐ Outpatient Lab ☐ Inpatient Unit: _______ ☐ ICU ☐ ED ☐ OR |
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---
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## Clinical History
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| Field | Entry |
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|-------|-------|
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| Seizure History | ☐ Yes ☐ No ☐ Unknown |
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| Last Seizure Date | |
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| Seizure Type | ☐ Generalized ☐ Focal ☐ Unknown |
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| Seizure Description | |
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### Current Medications (especially AEDs)
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| Medication | Dose | Last Taken |
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|------------|------|------------|
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| | | |
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| | | |
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| | | |
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| | | |
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### Other Relevant History
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| Field | Entry |
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|-------|-------|
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| Brain surgery/lesions | ☐ Yes ☐ No Details: |
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| Recent head injury | ☐ Yes ☐ No |
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| Developmental delay | ☐ Yes ☐ No |
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| Psychiatric history | ☐ Yes ☐ No |
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| Previous EEG | ☐ Yes (Date: _______) ☐ No |
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---
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## Pre-Recording Checklist
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| Item | Completed |
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|------|-----------|
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| Patient identity verified (two identifiers) | ☐ |
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| Order verified | ☐ |
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| Contraindications reviewed | ☐ |
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| Patient/family educated on procedure | ☐ |
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| Hair clean, no products | ☐ Yes ☐ No (document): |
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| Sleep deprivation completed (if ordered) | ☐ Yes ☐ No ☐ N/A |
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| Hours of sleep prior to EEG | hours |
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---
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## Technical Information
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### Equipment
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| Field | Entry |
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|-------|-------|
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| EEG System | |
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| Software Version | |
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| Amplifier Serial # | |
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| Electrode Type | ☐ Disc ☐ Cup ☐ Disposable ☐ Cap |
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### Electrode Placement
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| Field | Entry |
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|-------|-------|
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| Placement System | ☐ International 10-20 ☐ 10-10 ☐ Modified (describe) |
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| Reference Electrode | |
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| Ground Electrode | |
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| Additional Electrodes | |
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### Impedance Check
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| Electrode | Pre (kΩ) | Post (kΩ) |
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|-----------|----------|-----------|
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| Fp1 | | |
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| Fp2 | | |
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| F7 | | |
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| F3 | | |
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| Fz | | |
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| F4 | | |
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| F8 | | |
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| T3/T7 | | |
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| C3 | | |
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| Cz | | |
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| C4 | | |
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| T4/T8 | | |
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| T5/P7 | | |
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| P3 | | |
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| Pz | | |
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| P4 | | |
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| T6/P8 | | |
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| O1 | | |
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| O2 | | |
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| A1/M1 | | |
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| A2/M2 | | |
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| ECG | | |
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| Other: | | |
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**All impedances <5 kΩ?** ☐ Yes ☐ No (document exceptions)
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---
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## Recording Parameters
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| Parameter | Setting |
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|-----------|---------|
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| Sensitivity | µV/mm |
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| Low Frequency Filter | Hz |
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| High Frequency Filter | Hz |
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| Notch Filter | ☐ On (___Hz) ☐ Off |
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| Display Speed | mm/sec |
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| Sampling Rate | Hz |
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### Montages Used
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☐ Longitudinal bipolar (double banana)
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☐ Transverse bipolar
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☐ Referential (average)
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☐ Referential (ear)
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☐ Other: _______
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---
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## Activation Procedures
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### Hyperventilation
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| Field | Entry |
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|-------|-------|
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| Performed? | ☐ Yes ☐ No |
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| If No, reason: | ☐ Medical contraindication ☐ Patient unable ☐ Not ordered |
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| Duration | minutes |
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| Patient effort | ☐ Good ☐ Fair ☐ Poor |
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| Start time | |
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| Stop time | |
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| EEG changes during HV? | ☐ Yes (describe) ☐ No |
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| Clinical symptoms during HV? | ☐ Yes (describe) ☐ No |
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| Build-up present? | ☐ Yes ☐ No |
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| Resolution after HV? | ☐ Normal ☐ Prolonged |
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### Photic Stimulation
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| Field | Entry |
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|-------|-------|
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| Performed? | ☐ Yes ☐ No |
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| If No, reason: | |
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| Start time | |
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| Stop time | |
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| Lamp distance | cm |
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| Eyes condition | ☐ Closed ☐ Open ☐ Both |
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**Frequencies tested and response:**
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| Frequency (Hz) | Photic driving? | Photoparoxysmal response? |
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|----------------|-----------------|---------------------------|
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| 1 | ☐ | ☐ |
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| 3 | ☐ | ☐ |
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| 5 | ☐ | ☐ |
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| 7 | ☐ | ☐ |
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| 10 | ☐ | ☐ |
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| 13 | ☐ | ☐ |
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| 15 | ☐ | ☐ |
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| 18 | ☐ | ☐ |
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| 20 | ☐ | ☐ |
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| 25 | ☐ | ☐ |
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| 30 | ☐ | ☐ |
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**Photomyoclonic response?** ☐ Yes ☐ No
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### Sleep
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| Field | Entry |
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|-------|-------|
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| Sleep achieved? | ☐ Yes ☐ No |
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| Sleep stage achieved | ☐ Drowsy ☐ Stage I ☐ Stage II ☐ Deeper |
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| Method | ☐ Natural ☐ Sleep-deprived ☐ Sedation (medication: _______) |
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| Sleep spindles present? | ☐ Yes ☐ No |
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| Vertex waves present? | ☐ Yes ☐ No |
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| K-complexes present? | ☐ Yes ☐ No |
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---
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## Patient State/Behavior During Recording
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| State | Time (approximate) |
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|-------|-------------------|
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| Awake, eyes open | |
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| Awake, eyes closed | |
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| Drowsy | |
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| Asleep | |
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### Patient Cooperation
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☐ Excellent - fully cooperative
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☐ Good - generally cooperative
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☐ Fair - some difficulty
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☐ Poor - unable to cooperate (describe): _______
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---
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## Technologist Observations
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### Clinical Events During Recording
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☐ No clinical events observed
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| Time | Event Description | EEG Correlation Noted? |
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|------|------------------|------------------------|
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| | | ☐ Yes ☐ No |
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| | | ☐ Yes ☐ No |
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| | | ☐ Yes ☐ No |
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### Artifacts Noted
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☐ Muscle/EMG
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☐ Eye movement/blink
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☐ Movement
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☐ Electrode/technical
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☐ 60 Hz/electrical
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☐ ECG
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☐ Respiration
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☐ Sweat
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☐ Other: _______
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### Preliminary Observations (not interpretation)
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☐ Symmetric background
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☐ Asymmetric background
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☐ Slowing noted
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☐ Sharp waveforms noted
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☐ Seizure activity observed
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☐ Other findings: _______
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---
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## Technical Quality Assessment
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| Criterion | Met? |
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|-----------|------|
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| Adequate duration (≥20 min) | ☐ Yes ☐ No |
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| Acceptable impedances | ☐ Yes ☐ No |
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| Multiple montages recorded | ☐ Yes ☐ No |
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| Activation procedures completed | ☐ Yes ☐ N/A |
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| Sleep recorded (if ordered) | ☐ Yes ☐ N/A |
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| Minimal artifact | ☐ Yes ☐ No |
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| Calibration documented | ☐ Yes ☐ No |
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**Overall Technical Quality:** ☐ Excellent ☐ Good ☐ Fair ☐ Poor
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---
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## Post-Recording
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| Field | Entry |
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|-------|-------|
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| Electrodes removed | ☐ Yes |
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| Scalp inspected | ☐ Normal ☐ Irritation noted: |
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| Patient discharged from lab | Time: |
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| Patient condition at discharge | ☐ Baseline ☐ Changed (describe): |
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| Study uploaded to reading system | ☐ Yes |
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| Priority | ☐ Routine ☐ Urgent ☐ STAT |
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---
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## Technologist Attestation
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| Field | Entry |
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|-------|-------|
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| Technologist Name | |
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| Credentials | |
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| Signature | |
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| Date | |
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| Time | |
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---
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## Physician Review (if immediate review)
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| Field | Entry |
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|-------|-------|
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| Reviewed By | |
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| Date/Time | |
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| Preliminary Impression | |
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| Signature | |
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---
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*Form FRM-EEG-001 Rev 1.0 - EEG Recording Log*
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Reference in New Lab Ticket
Block a user