# EEG Recording Log

| Form ID | FRM-EEG-001 | Revision | 1.0 |
|---------|-------------|----------|-----|

---

## Patient Information

| Field | Entry |
|-------|-------|
| Patient Name | |
| MRN | |
| Date of Birth | |
| Age | |
| Sex | ☐ Male ☐ Female |
| Study Date | |
| Study Time Start | |
| Study Time End | |
| Study Duration | minutes |

---

## Ordering Information

| Field | Entry |
|-------|-------|
| Ordering Physician | |
| Study Type | ☐ Routine EEG ☐ Sleep-Deprived EEG ☐ Ambulatory EEG ☐ Portable/Bedside ☐ Other: _______ |
| Clinical Indication | |
| Patient Location | ☐ Outpatient Lab ☐ Inpatient Unit: _______ ☐ ICU ☐ ED ☐ OR |

---

## Clinical History

| Field | Entry |
|-------|-------|
| Seizure History | ☐ Yes ☐ No ☐ Unknown |
| Last Seizure Date | |
| Seizure Type | ☐ Generalized ☐ Focal ☐ Unknown |
| Seizure Description | |

### Current Medications (especially AEDs)

| Medication | Dose | Last Taken |
|------------|------|------------|
| | | |
| | | |
| | | |
| | | |

### Other Relevant History

| Field | Entry |
|-------|-------|
| Brain surgery/lesions | ☐ Yes ☐ No Details: |
| Recent head injury | ☐ Yes ☐ No |
| Developmental delay | ☐ Yes ☐ No |
| Psychiatric history | ☐ Yes ☐ No |
| Previous EEG | ☐ Yes (Date: _______) ☐ No |

---

## Pre-Recording Checklist

| Item | Completed |
|------|-----------|
| Patient identity verified (two identifiers) | ☐ |
| Order verified | ☐ |
| Contraindications reviewed | ☐ |
| Patient/family educated on procedure | ☐ |
| Hair clean, no products | ☐ Yes ☐ No (document): |
| Sleep deprivation completed (if ordered) | ☐ Yes ☐ No ☐ N/A |
| Hours of sleep prior to EEG | hours |

---

## Technical Information

### Equipment

| Field | Entry |
|-------|-------|
| EEG System | |
| Software Version | |
| Amplifier Serial # | |
| Electrode Type | ☐ Disc ☐ Cup ☐ Disposable ☐ Cap |

### Electrode Placement

| Field | Entry |
|-------|-------|
| Placement System | ☐ International 10-20 ☐ 10-10 ☐ Modified (describe) |
| Reference Electrode | |
| Ground Electrode | |
| Additional Electrodes | |

### Impedance Check

| Electrode | Pre (kΩ) | Post (kΩ) |
|-----------|----------|-----------|
| Fp1 | | |
| Fp2 | | |
| F7 | | |
| F3 | | |
| Fz | | |
| F4 | | |
| F8 | | |
| T3/T7 | | |
| C3 | | |
| Cz | | |
| C4 | | |
| T4/T8 | | |
| T5/P7 | | |
| P3 | | |
| Pz | | |
| P4 | | |
| T6/P8 | | |
| O1 | | |
| O2 | | |
| A1/M1 | | |
| A2/M2 | | |
| ECG | | |
| Other: | | |

**All impedances <5 kΩ?** ☐ Yes ☐ No (document exceptions)

---

## Recording Parameters

| Parameter | Setting |
|-----------|---------|
| Sensitivity | µV/mm |
| Low Frequency Filter | Hz |
| High Frequency Filter | Hz |
| Notch Filter | ☐ On (___Hz) ☐ Off |
| Display Speed | mm/sec |
| Sampling Rate | Hz |

### Montages Used

☐ Longitudinal bipolar (double banana)
☐ Transverse bipolar
☐ Referential (average)
☐ Referential (ear)
☐ Other: _______

---

## Activation Procedures

### Hyperventilation

| Field | Entry |
|-------|-------|
| Performed? | ☐ Yes ☐ No |
| If No, reason: | ☐ Medical contraindication ☐ Patient unable ☐ Not ordered |
| Duration | minutes |
| Patient effort | ☐ Good ☐ Fair ☐ Poor |
| Start time | |
| Stop time | |
| EEG changes during HV? | ☐ Yes (describe) ☐ No |
| Clinical symptoms during HV? | ☐ Yes (describe) ☐ No |
| Build-up present? | ☐ Yes ☐ No |
| Resolution after HV? | ☐ Normal ☐ Prolonged |

### Photic Stimulation

| Field | Entry |
|-------|-------|
| Performed? | ☐ Yes ☐ No |
| If No, reason: | |
| Start time | |
| Stop time | |
| Lamp distance | cm |
| Eyes condition | ☐ Closed ☐ Open ☐ Both |

**Frequencies tested and response:**

| Frequency (Hz) | Photic driving? | Photoparoxysmal response? |
|----------------|-----------------|---------------------------|
| 1 | ☐ | ☐ |
| 3 | ☐ | ☐ |
| 5 | ☐ | ☐ |
| 7 | ☐ | ☐ |
| 10 | ☐ | ☐ |
| 13 | ☐ | ☐ |
| 15 | ☐ | ☐ |
| 18 | ☐ | ☐ |
| 20 | ☐ | ☐ |
| 25 | ☐ | ☐ |
| 30 | ☐ | ☐ |

**Photomyoclonic response?** ☐ Yes ☐ No

### Sleep

| Field | Entry |
|-------|-------|
| Sleep achieved? | ☐ Yes ☐ No |
| Sleep stage achieved | ☐ Drowsy ☐ Stage I ☐ Stage II ☐ Deeper |
| Method | ☐ Natural ☐ Sleep-deprived ☐ Sedation (medication: _______) |
| Sleep spindles present? | ☐ Yes ☐ No |
| Vertex waves present? | ☐ Yes ☐ No |
| K-complexes present? | ☐ Yes ☐ No |

---

## Patient State/Behavior During Recording

| State | Time (approximate) |
|-------|-------------------|
| Awake, eyes open | |
| Awake, eyes closed | |
| Drowsy | |
| Asleep | |

### Patient Cooperation

☐ Excellent - fully cooperative
☐ Good - generally cooperative
☐ Fair - some difficulty
☐ Poor - unable to cooperate (describe): _______

---

## Technologist Observations

### Clinical Events During Recording

☐ No clinical events observed

| Time | Event Description | EEG Correlation Noted? |
|------|------------------|------------------------|
| | | ☐ Yes ☐ No |
| | | ☐ Yes ☐ No |
| | | ☐ Yes ☐ No |

### Artifacts Noted

☐ Muscle/EMG
☐ Eye movement/blink
☐ Movement
☐ Electrode/technical
☐ 60 Hz/electrical
☐ ECG
☐ Respiration
☐ Sweat
☐ Other: _______

### Preliminary Observations (not interpretation)

☐ Symmetric background
☐ Asymmetric background
☐ Slowing noted
☐ Sharp waveforms noted
☐ Seizure activity observed
☐ Other findings: _______

---

## Technical Quality Assessment

| Criterion | Met? |
|-----------|------|
| Adequate duration (≥20 min) | ☐ Yes ☐ No |
| Acceptable impedances | ☐ Yes ☐ No |
| Multiple montages recorded | ☐ Yes ☐ No |
| Activation procedures completed | ☐ Yes ☐ N/A |
| Sleep recorded (if ordered) | ☐ Yes ☐ N/A |
| Minimal artifact | ☐ Yes ☐ No |
| Calibration documented | ☐ Yes ☐ No |

**Overall Technical Quality:** ☐ Excellent ☐ Good ☐ Fair ☐ Poor

---

## Post-Recording

| Field | Entry |
|-------|-------|
| Electrodes removed | ☐ Yes |
| Scalp inspected | ☐ Normal ☐ Irritation noted: |
| Patient discharged from lab | Time: |
| Patient condition at discharge | ☐ Baseline ☐ Changed (describe): |
| Study uploaded to reading system | ☐ Yes |
| Priority | ☐ Routine ☐ Urgent ☐ STAT |

---

## Technologist Attestation

| Field | Entry |
|-------|-------|
| Technologist Name | |
| Credentials | |
| Signature | |
| Date | |
| Time | |

---

## Physician Review (if immediate review)

| Field | Entry |
|-------|-------|
| Reviewed By | |
| Date/Time | |
| Preliminary Impression | |
| Signature | |

---

*Form FRM-EEG-001 Rev 1.0 - EEG Recording Log*