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
