Clinical outcome review form
Date of last ECG
(valid for 6 months)
Date of last CxR
(valid for 12 months)
Date of last Blood tests (valid
for 6 months, unless patient’s
physical condition has changed)
Name
D.O.B
Hospital
Number
NOTE: REVIEWS MUST INCLUDE A FINAL ECT REVIEW 1 WEEK AFTER THE LAST
TREATMENT (this should include a MMSE and general assessment of side effects)
Blood investigations and urinalysis remain current for a period of six weeks, an ECG for six months
and a CXR for twelve months. For patients receiving ECT-M, an ECG is valid for six months and a
CXR for twelve months. Blood investigations and urinalysis should be repeated every six months or
sooner if the patient’s physical condition has changed
Treatment No at time of
assessment
Date
Sign
How do you feel
compared with
how you felt
before your
treatment started
/ after your last
treatment?
Date
Sign
Date
Sign
Date
Sign
Date
Sign
Date
Sign
Worse
No Change
Bit Better
Much Better
Capacity to
Yes / No
Consent
Clinical team assessment
Worse
Global Clinical
Response since
last assessment
No Change
Improved
Full Recover
Cognitive
Function
Outcome /
MMSE score
Worse
No Change
Improved
________________________________________________________________________________________________________________
CP16 ECT Policy – Appendix 4
Page 1 of 2
October 2012
Treatment No at time of
assessment
Date
Sign
How do you feel
compared with
how you felt
before your
treatment started
/ after your last
treatment?
Date
Sign
Date
Sign
Date
Sign
Date
Sign
Date
Sign
Worse
No Change
Bit Better
Much Better
Capacity to
Yes / No
Consent
Clinical team assessment
Worse
Global Clinical
Response since
last assessment
No Change
Improved
Full Recover
Cognitive
Function
Outcome /
MMSE score
Worse
No Change
Improved
________________________________________________________________________________________________________________
CP16 ECT Policy – Appendix 4
Page 2 of 2
October 2012