Electro Convulsive Therapy (ECT)
Treatment Centre
Berrywood Hospital
Northampton
01604 685590 / 91
[email protected]
4.3.4
Contents
Page
Medical Staff Documentation
1
Checklist for medical staff in preparing a patient for ECT
3
2
DOH Consent Form
4
3
ECT Referral
6
4
ECT prescription
11
5
Patients personal items
15
Nursing Documentation
1
Checklist for Nursing Staff in preparing a patient for ECT
16
2
ECT nursing care plan
17
3
Pre ECT checklist (inpatient)
21
4
ECT Patient Orientation Checklist
25
5
Multidisciplinary Review (subjective / objective view)
28
Treatment Centre Documentation
1
Pre ECT assessment
52
2
Treatment Centre ECT checklist
56
3
Day Patient ECT form
59
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
2
Checklist for Medical Staff in preparing a patient for ECT
Please tick
Yes
1.
Has the patient been consented for ECT?
2.
If the patient lacks capacity regarding ECT has the Mental Capacity
Assessment and Best Interests Checklist been completed?
3.
In preparation for ECT have the following been discussed and documented:
4.
5.

Discussed ECT procedure

Carer / advocate informed

Risks and Benefits of ECT explained

Have you reminded the patient that they can withdraw consent at any
time

An explanation regarding the risks of not having ECT and other
treatment alternatives

Driving risks / others post anaesthetic risks

Patient’s rights including access to independent advocacy

No pressure / coercion put on the patient’s decision
No
Have you completed:

Prescription Chart

Physical Examination

Bloods

ECG

Risk assessment for Venous Thromboembolism (VTE)
If travelling from a remote site has a letter to confirm the patient’s fitness to
travel been completed by the referring Consultant or nominated healthcare
professional
ENSURE CLINICAL STATUS OF THE PATIENT IS ASSESSED AFTER EVERY SESSION
Name:………...................................................... Signature:………………………………
Date:………….................................................... Designation:…………………………...
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
3
Consent Form 1
Patient Agreement to Electro Convulsive Therapy
Patient details (or pre-printed label)
NHS Organisation…………………………………..................
Patient’s first names………………………............................
Patient’s surname/family name…………………....................
Responsible health professional.........................................
Date of Birth.........................................................................
Job title................................................................................
NHS number (or other identifier)...........................................
Special requirements...........................................................
Male
Female
(e.g. other language/other communication method)
Proposed course of treatment: Electro Convulsive Therapy
UP TO A MAXIMUM COURSE OF TWELVE TREATMENT SESSIONS
B/L
U/L please circle
Further consent is required for a longer course of treatment. If initial treatment is not adequate, up to two further treatments may
be given in the same treatment session. The treating Psychiatrist would make this decision at the time of treatment.
Capacity to consent to be determined by referring consultant and appropriate
entry to that effect entered in the clinical notes.
Statement of health professional (to be filled in by health professional with appropriate knowledge of proposed
procedure, as specified in consent policy)
I have explained the procedure to the patient. In particular, I have explained:
The intended benefits..........................................................................................................................…………..
.................................................................................................................................................................
Frequently occurring temporary side-effects: headache, muscle ache, nausea, post treatment confusion, temporary memory
loss (fairly common)
Other serious risks that can occur: permanent memory loss has been reported, but is thought to be uncommon, mortality
1:50,000 (anaesthetic risk)
The dental risks have been fully explained to me:
The driving risks have been fully explained to me:
not applicable
yes
I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments and any
particular concerns of this patient. I have discussed the likely consequence of having no ECT treatment.
The following booklet/tape has been provided.........................................................................................
This procedure will involve:
general anaesthesia
Signed................................................................................................
Date......................................................
Name (PRINT)....................................................................................
Job title..................................................
Contact details (if patient wishes to discuss options later)........................................................................
Statement of interpreter (where appropriate)
I have interpreted the information above to the patient to the
best of my ability and in a way in which I believe she/he can understand.
Signed............................................................................................
Date......................................................
Name (PRINT)........................................................................................................................................................
Copy accepted by patient: yes / no (please circle)
1.2
GOLD COPY: CASE NOTES
WHITE COPY: PATIENT
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
4
1. Statement of patient
Patient identifier/label
Please read this form carefully. If your treatment has been planned in advance, you should already have your own copy, which
describes the benefits and risks of the proposed treatment. If not, you will be offered a copy now. If you have any further
questions, do ask – we are here to help you.
You have the right to change your mind at any time, including after you have signed this form.
I agree to the procedure or course of treatment described on this form namely Electro Convulsive Therapy (ECT).
I understand that you cannot give me a guarantee that a particular person will perform the procedure. The person will, however,
have appropriate experience.
I understand that I will have the opportunity to discuss the details of anaesthesia with an anaesthetist before the procedure.
I understand that any procedure in addition to those described on this form will only be carried out if it is necessary to save my
life or prevent serious harm to my health.
I have been told about additional procedures, which may become necessary during my treatment. I have listed below any
procedures which I do not wish to be carried out without further discussion.
................................................................................................................................................................................
................................................................................................................................................................................
I understand that I will be asked to confirm consent before every session.
Patient’s signature.............................................................................................
Date..........................................
Name (PRINT)........................................................................................................................................................
A witness should sign below if the patient is unable to sign but has indicated his or her consent. Young people/children
may also like a parent to sign here (see notes).
Signed..............................................................................................................
Date.........................................
Name (PRINT).................................................................................................
Date..........................................
Confirmation of consent (to be completed by a health professional when the patient is admitted for the procedure, if
the patient has signed the form in advance)
On behalf of the team treating the patient, I have confirmed with the patient that he/she has no further questions and wishes the
procedure to go ahead.
Signed..............................................................................................................
Name (PRINT)..........................................................................
Date..........................................
Job title.................................................
Important notes: (tick if applicable)
See also advance directive/living will (e.g. Jehovah’s Witness form)
Patient has withdrawn consent (ask patient to sign/date
here).......................................................................
Patient continues to consent before each treatment:
Tx 2
Tx 3
Tx 4
Tx 4
Tx 5
Tx 6
Tx 7
Tx 8
Tx 9
Tx 10
Tx 11
Date
Initial
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
5
Tx 12
ECT REFERRAL
Patient Details
Indications for ECT
Circle as Appropriate
Name:
Date of Birth:
Depression: Unipolar / Bipolar
Age:
Catatonia
Manic Episode
Other (please specify)
Ward/OP Sector:
Ethnic Origin:
Is the patient fit to travel to and from ECT? Yes / No
Consultant:
If yes, please provide a letter from the RC stating fitness
Completing Healthcare Professional:
to travel or RC to document on System One.
Date:
If no, please liaise with ECT team regarding plan of care.
Psychiatric History (please detail current / historical risks)
Past Medical/Surgical History (Please include previous operations / anaesthetics)
Current Medications & Allergies Please list ALL medications
Medication to be given on the morning of treatment:
Medication to be with-held on the morning of treatment:
Pre ECT Cognitive Status
MoCA:
Hamilton Score:
QIDS:
Becks:
Clinical Global Impression:
Care Pathway for ECT
Is the patient being treated as: (please circle)

Capacious and consenting to treatment?
Yes / No
NB. Consent form to be completed by Consultant only

Other assessment/s (please specify):
Under the Mental Capacity Act?
Is an IMCA required?
If Yes please refer to IMCA services.
Yes / No
Yes / No
Please complete MCA / BI forms

Under the Mental Health Act?
ECT Pack, Berrywood Hospital Treatment Centre,
Northamptonshire
Healthcare
Foundation
Trust
Where
appropriate has
a SOAD
application
been made?
Review Date: April 2018
Yes / No
6
PRE-ECT ASSESSMENT REFERRAL
(To be completed by the patient / carer and referring healthcare professional)
Please answer the following questions by circling Yes or No, add details where appropriate.
1. Are you allergic to anything?
Yes
No
10. What is your weight
11. What is your height
2.Do you bring up sputum from your chest:
Yes
No
11. Heart trouble
Yes
No
At intervals during the year?
Yes
No
12. High Blood Pressure
Yes
No
3. Does your chest ever sound wheezy?
Yes
No
13. Chest trouble / Asthma
Yes
No
4. Do you get more short of breath than
Yes
No
14. Liver disease / Jaundice
Yes
No
15. Kidney Disease
Yes
No
Now?
other people your own age?
Have you had or do you suffer from:
a) When climbing hills / stairs?
Yes
No
16. Diabetes
Yes
No
b) Walking on ground level?
Yes
No
17. Thyroid Disorders
Yes
No
18. Bleeding Tendencies
Yes
No
19. Thrombosis
Yes
No
20. Severe Anxiety / Depression
Yes
No
21. Epilepsy / convulsions
Yes
No
22. Sciatica / Back trouble
Yes
No
23. Neck or Jaw trouble
Yes
No
24. Heart Burn / indigestion /
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
5. Have you ever had pain or discomfort
in your chest:
a) When you exercise or hurry?
Yes
No
b) Does it disappear on resting?
Yes
No
6. Are you or your parents of African,
Caribbean or Eastern Mediterranean
Origin?
Yes
No
7. Have you or any member of your
family had a problem with an
Anaesthetic?
Yes
No
8. Have you been sick after an
Anaesthetic?
9. Do you have any loose / capped /
Hiatus Hernia
25. Do you smoke
Yes
No
How many?
Yes
No
26. Do you drink alcohol?
crowned or false teeth?
How much
27. Are you pregnant?
Are you taking any medication or drugs (including the pill)?
Please specify …………………………………………………………………………….
Have you had any previous operations /anaesthetics?
Is there anything you would like to discuss with your Anaesthetist?
Please specify …………………………………………………………………………….
Completed by:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
7
PHYSICAL ASSESSMENT
Cardiology
Gastrointestinal
Heart Sounds:
JVP
Apex
Respiratory
Breath Sounds
Chest Expansion
Added Sounds?
Inhaler use?
Yes
No
Neurology
Sensory
Motor
ANAESTHETIC ASSESSMENT
Dental Assessment
Admission Observations
Please circle:
Pulse
Blood Pressure
Dentures:
Yes / No
Temperature
Respiratory Rate
Loose teeth:
Yes / No
Oxygen Saturations
Consciousness level
Other:
BMI
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
8
ANAESTHETIC ASSESSMENT
ASA Score:
Date Completed:
Signed:
Print:
Any changes during treatment (e.g. ASA)
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
9
Medical Team - Monitoring of the patient’s clinical status and response to ECT.
Please enter the scores below of completed assessments (NB. shaded areas are not required) for pre and during the
course of ECT:
Pre
ECT
After
Tx 1
After
Tx 2
After
Tx 3
After
Tx 4
After
Tx 5
After
Tx 6
After
Tx 7
After
Tx 8
After
Tx 9
After
Tx 10
After
Tx 11
After
Tx 12
¾ days
post
ECT
CGI
HDRS 21 item
MoCA
Youngs Mania Scale
Post ECT follow up by Responsible Healthcare Professional / team.
Month 1
Month 2
Month 3
MoCA
Youngs Mania Scale
Clinical Interview
Review by the RC (sign)
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
10
ECT PRECRIPTION
Date Prescribed
B/L
Right
U/L
Print
and
Sign
Date
Given
B/L
Right
U/L
Tx
No
Current
Delivered %
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
Current Delivered
Mc
11
Seizure
1. None
2. Doubtful
3. Bilat Clonus
Duration of
seizure on EEG
Duration of motor seizure
observed
Comments
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
Print and Sign
12
ANAESTHETIC
Tx
no
Date
Nature of
Ventilation
Anaesthetic
Dose
Relaxant
Dose
Additional information
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
Anaesthetist
print and sign
13
NOTES TO THE PRESCRIBER
 If the patient is detained under The Mental Health Act (1983, 2007
amendments) treatment can be given under Section 58A, form T4, T5
(under 18’s), T6 or T8 (Sec 62 Emergency treatment) must be attached.
 If the patient is being treated under the Mental Capacity Act (MCA 2005)
Mental Capacity Assessment and Best Interests forms must be attached.
 If the patient is able to give valid and informed consent, an amended
Department of Health (DOH) consent form 1 must be completed fully and
attached.
 Please follow local protocol / guidelines for fasting prior to ECT. Patient
to have no solid food for 6 hours prior to treatment, however a small
amount of water may be consumed up to 2 hours prior to treatment.
 All routine physical medication should be taken on the morning of
treatment with a small amount of water, unless instructed otherwise.
 Significant medical history including diabetes should be discussed with
the Anaesthetist prior to treatment and a plan of care documented.
 A full blood count, biochemical screen and ECG should be performed on
all patients. Chest X-Ray should only be performed if the patient has
significant cardio-respiratory disorder.
 No more than two ECT’s are to be prescribed at one time. Review
between each treatment.
 ECT prescription is the responsibility of the patient’s team doctors. ECT
cannot be given without an up to date prescription (valid for 14 days).
 Pre-ECT assessment must be filled out in full.
 All day patients require an escort for their treatment sessions and
supervision for up to 24 hours at home.
 Please discuss and document fitness to drive (refer to the RCPsych
(2009) Depression, ECT and fitness to drive leaflet).
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
14
Personal Items
Date
Item removed /
retained
Returned
Signature
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
15
Nursing Documentation
Checklist for Nursing Staff in preparing a patient for ECT
The patient’s / carer’s experience of ECT and MDT comments after each session of ECT can
be completed in ward round or by inpatient nursing staff.
If receiving ECT as an outpatient the patient’s experience of ECT and MDT comments after
each session can be documented by the care co-ordinator.
Please tick
Yes
No
Before the start of treatment have the following been completed:

Nursing Care Plan

Nursing Care Plan signed by the patient (where possible)
On the day of treatment prior to ECT have the following been completed?
(please initial):
Treatment No
1
2
3
4
5
6
7
8
9
10
11
12
9
10
11
12
Pre ECT Checklist
ECT patient orientation
Have the following been reviewed and completed after each ECT treatment?
(please initial)
Treatment No
1
2
3
4
5
6
7
8
Patient’s Experience of ECT
Multi-disciplinary Review
Capacity / Consent Review
Review of Patient’s Clinical
Response and Cognition
Nursing Care plan evaluation
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
16
ECT NURSING CARE PLAN
Patient’s name.......................................
Date of birth..........................
Date formulated.....................................
Preferred Language......................
Identified patient need ……………………………………………………….................
....................................................................................................................................
....................................................................................................................................
Within NICE Technical Appraisal .............if not is patient aware?............................
Aims or expected outcomes:.....................................................................................
................................................................................................................................................
................................................................................................................................................
.............................................................................................................
Patient’s perception of proposed treatment:...........................................................................
................................................................................................................................................
................................................................................................................................................
............................................................................................................
Staff involved in escort duties should know the patient, be clear about their
responsibilities and understand any physical or / and medical conditions that may be
relevant. Importantly the escorts must understand what is expected of them in the
case of a psychiatric / medical crisis at or on the way to and from the Treatment
Centre; or if the patient attempts to leave the escorting staff.
Signed by (nurse).......................................................
patient......................................................... date...................................
Nursing Objectives
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
17

Inform Treatment Centre re proposed treatment.

Explain the procedure for ECT treatment to patient / relatives / carer as appropriate.

Ensure relevant documentation is completed (e.g. medical history, physical, bloods,
consent or appropriate MHA documentation, ECG, CXR) and that ECT is prescribed.

Ensure the patient is aware of the reasons they will be unable to have no solid food after
03:00am and that only a small amount of clear fluid may be consumed up to 07:00am on
the morning of treatment.

Staff on duty the night preceding treatment must be aware of treatment the next day and
ensure the patient is nil by mouth. A nursing care plan must be documented regarding
medication that needs to be omitted or given (on advice from referring healthcare
professional / RC).

On the morning of ECT, patient to be reassured and reminded again of nil by mouth, to
maintain nil by mouth status consideration should be given to the patient’s level of
observation.

Identify and ensure nurse escort (who is known to the patient) is aware of patient’s legal
status and of the proposed treatment.

On patient’s return to ward monitor condition including completion of ECT patient
orientation checklist.

Record treatment and relevant information in patient notes / System One.

Inform referring team and Treatment Centre of untoward effects.

Ensure patient is reviewed between treatments especially for cognitive impairment and
improvement in mood.
Other Comments
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
18
Evaluation of Individual Care Plan
Date &
Signature
Evaluation
Each entry must be signed including designation
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
19
Evaluation of Individual Care Plan
Date &
Signature
Evaluation
Each entry must be signed including designation
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
20
PRE ECT CHECKLIST
To be completed by ward nursing staff on day of planned treatment
Name:...............................DOB:.........Status:...................Ward.........................
Date
Date
Date
Date
Date
Date
/ X
/ X
/ X
/ X
/ X
/ X
Blood pressure
Pulse
Temperature
Weight
BM reading
Time BM taken
Pre ECT checks to be carried out by ward
nursing staff
Today’s treatment has been clearly explained
Patient is consenting to today’s treatment / MCA
Assessment completed if being treated under MCA
DOH consent form 1 is not void / signed / in date
and in case notes
Valid and relevant (1983 / 2007) forms are attached
to consent form (T4, T5, T6, T8)
ECT prescription chart completed in full and valid
Current medication chart available
ECG, X-ray, recent blood results available in case
notes
Any makeup/nail varnish removed / please inform
Treatment Centre if the patient is wearing contact
lenses / has dental implants
Hair free from styling products
Patient given opportunity to empty bladder before
leaving the ward
Any side effects or changes in physical health since
last treatment (this information is to be given to the
ECT clinic nurse on arrival)
Completed by: Signature
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
21
PRE ECT CHECKLIST
To be completed by ward nursing staff on day of planned treatment
Addressograph
Name:...............................DOB:.........Status:...................Ward.........................
Date
Date
Date
Date
Date
Date
/ X
/ X
/ X
/ X
/ X
/ X
Blood pressure
Pulse
Temperature
Weight
BM reading
Time BM taken
Pre ECT checks to be carried out by ward
nursing staff
Today’s treatment has been clearly explained
Patient is consenting to today’s treatment / MCA
Assessment completed if being treated under MCA
DOH consent form 1 is not void / signed / in date
and in case notes
Valid and relevant (1983 / 2007) forms are
attached to consent form (T4, T5, T6, T8)
ECT prescription chart completed in full and valid
Current medication chart available
ECG, X-ray, recent blood results available in case
notes
Any makeup/nail varnish removed / please inform
Treatment Centre if the patient is wearing contact
lenses / has dental implants
Hair free from styling products
Patient given opportunity to empty bladder before
leaving the ward
Any side effects or changes in physical health since
last treatment (this information is to be given to the
ECT clinic nurse on arrival)
Completed by: Signature
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
22
PRE ECT CHECKLIST
To be completed by ward nursing staff on day of planned treatment
Name:...............................DOB:.........Status:...................Ward.........................
Date
Date
Date
Date
Date
Date
/ X
/ X
/ X
/ X
/ X
/ X
Blood pressure
Pulse
Temperature
Weight
BM reading
Time BM taken
Pre ECT checks to be carried out by ward
nursing staff
Today’s treatment has been clearly explained
Patient is consenting to today’s treatment / MCA
Assessment completed if being treated under MCA
DOH consent form 1 is not void / signed / in date
and in case notes
Valid and relevant MHA (1983 / 2007) forms are
attached to consent form (T4, T5, T6, T8)
ECT prescription chart completed in full and valid
Current medication chart available
ECG, X-ray, recent blood results available in case
notes
Any makeup/nail varnish removed / please inform
Treatment Centre if the patient is wearing contact
lenses / has dental implants
Hair free from styling products
Patient given opportunity to empty bladder before
leaving the ward
Any side effects or changes in physical health since
last treatment (this information is to be given to the
ECT clinic nurse on arrival)
Completed by: Signature
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
23
PRE ECT CHECKLIST
To be completed by ward nursing staff on day of planned treatment
Name:...............................DOB:.........Status:...................Ward.........................
Date
Date
Date
Date
Date
Date
/ X
/ X
/ X
/ X
/ X
/ X
Blood pressure
Pulse
Temperature
Weight
BM reading
Time BM taken
Pre ECT checks to be carried out by ward
nursing staff
Today’s treatment has been clearly explained
Patient is consenting to today’s treatment / MCA
Assessment completed if being treated under MCA
DOH consent form 1 is not void / signed / in date
and in case notes
Valid and relevant (1983 / 2007) forms are attached
to consent form (T4, T5, T6, T8)
ECT prescription chart completed in full and valid
Current medication chart available
ECG, X-ray, recent blood results available in case
notes
Any makeup/nail varnish removed / please inform
Treatment Centre if the patient is wearing contact
lenses / has dental implants
Hair free from styling products
Patient given opportunity to empty bladder before
leaving the ward
Any side effects or changes in physical health since
last treatment (this information is to be given to the
ECT clinic nurse on arrival)
Completed by: Signature
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
24
ECT PATIENT ORIENTATION CHECKLIST
Addressograph
This checklist is completed pre and post ECT by nursing staff to assess the patient’s
orientation. It provides a baseline recording for staff so as to compare this information
throughout the day of treatment and to where necessary, report any changes in the patient’s
level of orientation to the medical team responsible for the patients’ care.
Treatment
Date:
Pre ECT
Post ECT
Secondary recovery
Post ECT
(4 hours after
returning to the
ward)
Pre ECT
Post ECT
Secondary recovery
Post ECT
(4 hours after
returning to the
ward)
Pre ECT
Post ECT
Secondary recovery
Post ECT
(4 hours after
returning to the
ward)
Pre ECT
Post ECT
Secondary recovery
Post ECT
(4 hours after
returning to the
ward)
Number: 1
What is your full name?
What is your date of birth?
Do you know where you are?
What year is it?
What day of the week is it?
Treatment
Date:
Number: 2
What is your full name?
What is your date of birth?
Do you know where you are?
What year is it?
What day of the week is it?
Treatment
Date:
Number: 3
What is your full name?
What is your date of birth?
Do you know where you are?
What year is it?
What day of the week is it?
Treatment
Date:
Number: 4
What is your full name?
What is your date of birth?
Do you know where you are?
What year is it?
What day of the week is it?
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
25
ECT PATIENT ORIENTATION CHECKLIST
Addressograph
This checklist is completed pre and post ECT by nursing staff to assess the patient’s
orientation. It provides a baseline recording for staff so as to compare this information
throughout the day of treatment and to where necessary, report any changes in the patient’s
level of orientation to the medical team responsible for the patients’ care.
Treatment
Date:
Pre ECT
Post ECT
Secondary recovery
Post ECT
(4 hours after
returning to the
ward)
Pre ECT
Post ECT
Secondary recovery
Post ECT
(4 hours after
returning to the
ward)
Pre ECT
Post ECT
Secondary recovery
Post ECT
(4 hours after
returning to the
ward)
Pre ECT
Post ECT
Secondary recovery
Post ECT
(4 hours after
returning to the
ward)
Number: 5
What is your full name?
What is your date of birth?
Do you know where you are?
What year is it?
What day of the week is it?
Treatment
Date:
Number: 6
What is your full name?
What is your date of birth?
Do you know where you are?
What year is it?
What day of the week is it?
Treatment
Date:
Number: 7
What is your full name?
What is your date of birth?
Do you know where you are?
What year is it?
What day of the week is it?
Treatment
Date:
Number: 8
What is your full name?
What is your date of birth?
Do you know where you are?
What year is it?
What day of the week is it?
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
26
ECT PATIENT ORIENTATION CHECKLIST
Addressograph
This checklist is completed pre and post ECT by nursing staff to assess the patient’s
orientation. It provides a baseline recording for staff so as to compare this information
throughout the day of treatment and to where necessary, report any changes in the patient’s
level of orientation to the medical team responsible for the patients’ care.
Treatment
Date:
Pre ECT
Post ECT
Secondary recovery
Post ECT
(4 hours after
returning to the
ward)
Pre ECT
Post ECT
Secondary recovery
Post ECT
(4 hours after
returning to the
ward)
Pre ECT
Post ECT
Secondary recovery
Post ECT
(4 hours after
returning to the
ward)
Pre ECT
Post ECT
Secondary recovery
Post ECT
(4 hours after
returning to the
ward)
Number: 9
What is your full name?
What is your date of birth?
Do you know where you are?
What year is it?
What day of the week is it?
Treatment
Date:
Number: 10
What is your full name?
What is your date of birth?
Do you know where you are?
What year is it?
What day of the week is it?
Treatment
Date:
Number: 11
What is your full name?
What is your date of birth?
Do you know where you are?
What year is it?
What day of the week is it?
Treatment
Date:
Number: 12
What is your full name?
What is your date of birth?
Do you know where you are?
What year is it?
What day of the week is it?
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
27
Multi-disciplinary Review
Please complete the following with the patient if possible. The reason for this is to give the
multidisciplinary team (MDT) an idea of how effective the patient thinks the treatment is
(subjective view). This is to be completed with the patient after each ECT treatment (post
ECT) and where possible signed by the patient.
The MDT also should complete the
comments at a ward round (objective view). The information is beneficial to the Lead ECT
Consultant when considering whether or not to change a treatment dose.
Treatment No 1
Patient Experience
Please circle

Do you feel / notice any improvement since starting
treatment?
Yes / No

Do others say they notice any improvement?
Yes / No

Do you think you are having side effects because of ECT?
Yes / No

After your treatment do you have any difficulty remembering
things?
Yes / No
Carer’s Comments (if any):
Comments (if any):
Patient signature:
Date:
Signature of Nurse:
Date:
Multi-Disciplinary Comments
Please circle

Have members of the MDT noticed any improvement?
Yes / No

Are any members of the MDT aware of the patient
experiencing any side effects?
Yes / No

Are there any difficulties with impairment and ECT?
Yes / No

Any changes (physically / mentally) since the last ECT?
Yes / No
Comments (if any):
Signature:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
28
Treatment 1
Consent / Capacity Review
Has the patient been asked if they have all the information they need
and whether they have any more questions or queries at each
treatment?
Yes / No
If no please specify reason why and action taken:
Is the patient confirming ongoing consent to treatment?
Yes / No
If no has consent now been withdrawn? (please specify):
Where the patient lacks mental capacity regarding ECT has this
been assessed by the RC or healthcare professional?
Yes / No
Has this assessment been documented 24 hours before treatment?
Yes / No
Does the patient have fluctuating capacity presently and in
agreement for treatment?
Yes / No
Does the Responsible Clinician plan to offer the patient with
fluctuating capacity ECT under the T6?
Yes / No
If no please advise on plan of care:
Monitoring the Patient’s Clinical Response and Cognition.
Is the patient co-operative with assessments?
Yes / No
If no how are these issues being addressed:
Please record the outcomes of the following assessment/s after
Treatment 1:
Assessment Scores
Clinical Global Impression Scale (CGI)
Any comments:
Signed:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
29
Multi-disciplinary Review
Please complete the following with the patient if possible. The reason for this is to give the
multidisciplinary team (MDT) an idea of how effective the patient thinks the treatment is
(subjective view). This is to be completed with the patient after each ECT treatment (post
ECT) and where possible signed by the patient.
The MDT also should complete the
comments at a ward round (objective view). The information is beneficial to the Lead ECT
Consultant when considering whether or not to change a treatment dose.
Treatment No 2
Patient Experience
Please circle

Do you feel / notice any improvement since starting
treatment?
Yes / No

Do others say they notice any improvement?
Yes / No

Do you think you are having side effects because of ECT?
Yes / No

After your treatment do you have any difficulty remembering
things?
Yes / No
Carer’s Comments (if any):
Comments (if any):
Patient signature:
Date:
Signature of Nurse:
Date:
Multi-Disciplinary Comments
Please circle

Have members of the MDT noticed any improvement?
Yes / No

Are any members of the MDT aware of the patient
experiencing any side effects?
Yes / No

Are there any difficulties with impairment and ECT?
Yes / No

Any changes (physically / mentally) since the last ECT?
Yes / No
Comments (if any):
Signature:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
30
Treatment 2
Consent / Capacity Review
Has the patient been asked if they have all the information they need
and whether they have any more questions or queries at each
treatment?
Yes / No
If no please specify reason why and action taken:
Is the patient confirming on-going consent to treatment?
Yes / No
If no has consent now been withdrawn? (please specify):
Where the patient lacks mental capacity regarding ECT has this
been assessed by the RC or healthcare professional?
Yes / No
Has this assessment been documented 24 hours before treatment?
Yes / No
Does the patient have fluctuating capacity presently and in
agreement for treatment?
Yes / No
Does the Responsible Clinician plan to offer the patient with
fluctuating capacity ECT under the T6?
Yes / No
If no please advise on plan of care:
Monitoring the Patient’s Clinical Response and Cognition.
Is the patient co-operative with assessments?
Yes / No
If no how are these issues being addressed:
Please record the outcomes of the following assessment/s after
Treatment 2:
Assessment Scores
Clinical Global Impression Scale (CGI)
Hamilton Depression Rating Scale (HDRS)
Any comments:
Signed:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
31
Multi-disciplinary Review
Please complete the following with the patient if possible. The reason for this is to give the
multidisciplinary team (MDT) an idea of how effective the patient thinks the treatment is
(subjective view). This is to be completed with the patient after each ECT treatment (post
ECT) and where possible signed by the patient.
The MDT also should complete the
comments at a ward round (objective view). The information is beneficial to the Lead ECT
Consultant when considering whether or not to change a treatment dose.
Treatment No 3
Patient Experience
Please circle

Do you feel / notice any improvement since starting
treatment?
Yes / No

Do others say they notice any improvement?
Yes / No

Do you think you are having side effects because of ECT?
Yes / No

After your treatment do you have any difficulty remembering
things?
Yes / No
Carer’s Comments (if any):
Comments (if any):
Patient signature:
Date:
Signature of Nurse:
Date:
Multi-Disciplinary Comments
Please circle

Have members of the MDT noticed any improvement?
Yes / No

Are any members of the MDT aware of the patient
experiencing any side effects?
Yes / No

Are there any difficulties with impairment and ECT?
Yes / No

Any changes (physically / mentally) since the last ECT?
Yes / No
Comments (if any):
Signature:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
32
Treatment 3
Consent / Capacity Review
Has the patient been asked if they have all the information they need
and whether they have any more questions or queries at each
treatment?
Yes / No
If no please specify reason why and action taken:
Is the patient confirming on-going consent to treatment?
Yes / No
If no has consent now been withdrawn? (please specify):
Where the patient lacks mental capacity regarding ECT has this
been assessed by the RC or healthcare professional?
Yes / No
Has this assessment been documented 24 hours before treatment?
Yes / No
Does the patient have fluctuating capacity presently and in
agreement for treatment?
Yes / No
Does the Responsible Clinician plan to offer the patient with
fluctuating capacity ECT under the T6?
Yes / No
If no please advise on plan of care:
Monitoring the Patient’s Clinical Response and Cognition.
Is the patient co-operative with assessments?
Yes / No
If no how are these issues being addressed:
Please record the outcomes of the following assessment/s after
Treatment 3:
Assessment Scores
Clinical Global Impression Scale (CGI)
Any comments:
Signed:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
33
Multi-disciplinary Review
Please complete the following with the patient if possible. The reason for this is to give the
multidisciplinary team (MDT) an idea of how effective the patient thinks the treatment is
(subjective view). This is to be completed with the patient after each ECT treatment (post
ECT) and where possible signed by the patient.
The MDT also should complete the
comments at a ward round (objective view). The information is beneficial to the Lead ECT
Consultant when considering whether or not to change a treatment dose.
Treatment No 4
Patient Experience
Please circle

Do you feel / notice any improvement since starting
treatment?
Yes / No

Do others say they notice any improvement?
Yes / No

Do you think you are having side effects because of ECT?
Yes / No

After your treatment do you have any difficulty remembering
things?
Yes / No
Carer’s Comments (if any):
Comments (if any):
Patient signature:
Date:
Signature of Nurse:
Date:
Multi-Disciplinary Comments
Please circle

Have members of the MDT noticed any improvement?
Yes / No

Are any members of the MDT aware of the patient
experiencing any side effects?
Yes / No

Are there any difficulties with impairment and ECT?
Yes / No

Any changes (physically / mentally) since the last ECT?
Yes / No
Comments (if any):
Signature:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
34
Treatment 4
Consent / Capacity Review
Has the patient been asked if they have all the information they need
and whether they have any more questions or queries at each
treatment?
Yes / No
If no please specify reason why and action taken:
Is the patient confirming on-going consent to treatment?
Yes / No
If no has consent now been withdrawn? (please specify):
Where the patient lacks mental capacity regarding ECT has this
been assessed by the RC or healthcare professional?
Yes / No
Has this assessment been documented 24 hours before treatment?
Yes / No
Does the patient have fluctuating capacity presently and in
agreement for treatment?
Yes / No
Does the Responsible Clinician plan to offer the patient with
fluctuating capacity ECT under the T6?
Yes / No
If no please advise on plan of care:
Monitoring the Patient’s Clinical Response and Cognition.
Is the patient co-operative with assessments?
Yes / No
If no how are these issues being addressed:
Please record the outcomes of the following assessment/s after
Treatment 4:
Assessment Scores
Clinical Global Impression Scale (CGI)
Hamilton Depression Rating Scale (HDRS)
Montreal Cognitive Assessment (MoCA)
Any comments:
Signed:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
35
Multi-disciplinary Review
Please complete the following with the patient if possible. The reason for this is to give the
multidisciplinary team (MDT) an idea of how effective the patient thinks the treatment is
(subjective view). This is to be completed with the patient after each ECT treatment (post
ECT) and where possible signed by the patient.
The MDT also should complete the
comments at a ward round (objective view). The information is beneficial to the Lead ECT
Consultant when considering whether or not to change a treatment dose.
Treatment No 5
Patient Experience
Please circle

Do you feel / notice any improvement since starting
treatment?
Yes / No

Do others say they notice any improvement?
Yes / No

Do you think you are having side effects because of ECT?
Yes / No

After your treatment do you have any difficulty remembering
things?
Yes / No
Carer’s Comments (if any):
Comments (if any):
Patient signature:
Date:
Signature of Nurse:
Date:
Multi-Disciplinary Comments
Please circle

Have members of the MDT noticed any improvement?
Yes / No

Are any members of the MDT aware of the patient
experiencing any side effects?
Yes / No

Are there any difficulties with impairment and ECT?
Yes / No

Any changes (physically / mentally) since the last ECT?
Yes / No
Comments (if any):
Signature:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
36
Treatment 5
Consent / Capacity Review
Has the patient been asked if they have all the information they need
and whether they have any more questions or queries at each
treatment?
Yes / No
If no please specify reason why and action taken:
Is the patient confirming on-going consent to treatment?
Yes / No
If no has consent now been withdrawn? (please specify):
Where the patient lacks mental capacity regarding ECT has this
been assessed by the RC or healthcare professional?
Yes / No
Has this assessment been documented 24 hours before treatment?
Yes / No
Does the patient have fluctuating capacity presently and in
agreement for treatment?
Yes / No
Does the Responsible Clinician plan to offer the patient with
fluctuating capacity ECT under the T6?
Yes / No
If no please advise on plan of care:
Monitoring the Patient’s Clinical Response and Cognition.
Is the patient co-operative with assessments?
Yes / No
If no how are these issues being addressed:
Please record the outcomes of the following assessment/s after
Treatment 5:
Assessment Scores
Clinical Global Impression Scale (CGI)
Any comments:
Signed:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
37
Multi-disciplinary Review
Please complete the following with the patient if possible. The reason for this is to give the
multidisciplinary team (MDT) an idea of how effective the patient thinks the treatment is
(subjective view). This is to be completed with the patient after each ECT treatment (post
ECT) and where possible signed by the patient.
The MDT also should complete the
comments at a ward round (objective view). The information is beneficial to the Lead ECT
Consultant when considering whether or not to change a treatment dose.
Treatment No 6
Patient Experience
Please circle

Do you feel / notice any improvement since starting
treatment?
Yes / No

Do others say they notice any improvement?
Yes / No

Do you think you are having side effects because of ECT?
Yes / No

After your treatment do you have any difficulty remembering
things?
Yes / No
Carer’s Comments (if any):
Comments (if any):
Patient signature:
Date:
Signature of Nurse:
Date:
Multi-Disciplinary Comments
Please circle

Have members of the MDT noticed any improvement?
Yes / No

Are any members of the MDT aware of the patient
experiencing any side effects?
Yes / No

Are there any difficulties with impairment and ECT?
Yes / No

Any changes (physically / mentally) since the last ECT?
Yes / No
Comments (if any):
Signature:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
38
Treatment 6
Consent / Capacity Review
Has the patient been asked if they have all the information they need
and whether they have any more questions or queries at each
treatment?
Yes / No
If no please specify reason why and action taken:
Is the patient confirming ongoing consent to treatment?
Yes / No
If no has consent now been withdrawn? (please specify):
Where the patient lacks mental capacity regarding ECT has this
been assessed by the RC or healthcare professional?
Yes / No
Has this assessment been documented 24 hours before treatment?
Yes / No
Does the patient have fluctuating capacity presently and in
agreement for treatment?
Yes / No
Does the Responsible Clinician plan to offer the patient with
fluctuating capacity ECT under the T6?
Yes / No
If no please advise on plan of care:
Monitoring the Patient’s Clinical Response and Cognition.
Is the patient co-operative with assessments?
Yes / No
If no how are these issues being addressed:
Please record the outcomes of the following assessment/s after
Treatment 6:
Assessment Scores
Clinical Global Impression Scale (CGI)
Hamilton Depression Rating Scale (HDRS)
Any comments:
Signed:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
39
Multi-disciplinary Review
Please complete the following with the patient if possible. The reason for this is to give the
multidisciplinary team (MDT) an idea of how effective the patient thinks the treatment is
(subjective view). This is to be completed with the patient after each ECT treatment (post
ECT) and where possible signed by the patient.
The MDT also should complete the
comments at a ward round (objective view). The information is beneficial to the Lead ECT
Consultant when considering whether or not to change a treatment dose.
Treatment No 7
Patient Experience
Please circle

Do you feel / notice any improvement since starting
treatment?
Yes / No

Do others say they notice any improvement?
Yes / No

Do you think you are having side effects because of ECT?
Yes / No

After your treatment do you have any difficulty remembering
things?
Yes / No
Carer’s Comments (if any):
Comments (if any):
Patient signature:
Date:
Signature of Nurse:
Date:
Multi-Disciplinary Comments
Please circle

Have members of the MDT noticed any improvement?
Yes / No

Are any members of the MDT aware of the patient
experiencing any side effects?
Yes / No

Are there any difficulties with impairment and ECT?
Yes / No

Any changes (physically / mentally) since the last ECT?
Yes / No
Comments (if any):
Signature:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
40
Treatment 7
Consent / Capacity Review
Has the patient been asked if they have all the information they need
and whether they have any more questions or queries at each
treatment?
Yes / No
If no please specify reason why and action taken:
Is the patient confirming ongoing consent to treatment?
Yes / No
If no has consent now been withdrawn? (please specify):
Where the patient lacks mental capacity regarding ECT has this
been assessed by the RC or healthcare professional?
Yes / No
Has this assessment been documented 24 hours before treatment?
Yes / No
Does the patient have fluctuating capacity presently and in
agreement for treatment?
Yes / No
Does the Responsible Clinician plan to offer the patient with
fluctuating capacity ECT under the T6?
Yes / No
If no please advise on plan of care:
Monitoring the Patient’s Clinical Response and Cognition.
Is the patient co-operative with assessments?
Yes / No
If no how are these issues being addressed:
Please record the outcomes of the following assessment/s after
Treatment 7:
Assessment Scores
Clinical Global Impression Scale (CGI)
Any comments:
Signed:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
41
Multi-disciplinary Review
Please complete the following with the patient if possible. The reason for this is to give the
multidisciplinary team (MDT) an idea of how effective the patient thinks the treatment is
(subjective view). This is to be completed with the patient after each ECT treatment (post
ECT) and where possible signed by the patient.
The MDT also should complete the
comments at a ward round (objective view). The information is beneficial to the Lead ECT
Consultant when considering whether or not to change a treatment dose.
Treatment No 8
Patient Experience
Please circle

Do you feel / notice any improvement since starting
treatment?
Yes / No

Do others say they notice any improvement?
Yes / No

Do you think you are having side effects because of ECT?
Yes / No

After your treatment do you have any difficulty remembering
things?
Yes / No
Carer’s Comments (if any):
Comments (if any):
Patient signature:
Date:
Signature of Nurse:
Date:
Multi-Disciplinary Comments
Please circle

Have members of the MDT noticed any improvement?
Yes / No

Are any members of the MDT aware of the patient
experiencing any side effects?
Yes / No

Are there any difficulties with impairment and ECT?
Yes / No

Any changes (physically / mentally) since the last ECT?
Yes / No
Comments (if any):
Signature:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
42
Treatment 8
Consent / Capacity Review
Has the patient been asked if they have all the information they need
and whether they have any more questions or queries at each
treatment?
Yes / No
If no please specify reason why and action taken:
Is the patient confirming ongoing consent to treatment?
Yes / No
If no has consent now been withdrawn? (please specify):
Where the patient lacks mental capacity regarding ECT has this
been assessed by the RC or healthcare professional?
Yes / No
Has this assessment been documented 24 hours before treatment?
Yes / No
Does the patient have fluctuating capacity presently and in
agreement for treatment?
Yes / No
Does the Responsible Clinician plan to offer the patient with
fluctuating capacity ECT under the T6?
Yes / No
If no please advise on plan of care:
Monitoring the Patient’s Clinical Response and Cognition.
Is the patient co-operative with assessments?
Yes / No
If no how are these issues being addressed:
Please record the outcomes of the following assessment/s after
Treatment 8:
Assessment Scores
Clinical Global Impression Scale (CGI)
Hamilton Depression Rating Scale (HDRS)
Montreal Cognitive Assessment (MoCA)
Any comments:
Signed:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
43
Multi-disciplinary Review
Please complete the following with the patient if possible. The reason for this is to give the
multidisciplinary team (MDT) an idea of how effective the patient thinks the treatment is
(subjective view). This is to be completed with the patient after each ECT treatment (post
ECT) and where possible signed by the patient.
The MDT also should complete the
comments at a ward round (objective view). The information is beneficial to the Lead ECT
Consultant when considering whether or not to change a treatment dose.
Treatment No 9
Patient Experience
Please circle

Do you feel / notice any improvement since starting
treatment?
Yes / No

Do others say they notice any improvement?
Yes / No

Do you think you are having side effects because of ECT?
Yes / No

After your treatment do you have any difficulty remembering
things?
Yes / No
Carer’s Comments (if any):
Comments (if any):
Patient signature:
Date:
Signature of Nurse:
Date:
Multi-Disciplinary Comments
Please circle

Have members of the MDT noticed any improvement?
Yes / No

Are any members of the MDT aware of the patient
experiencing any side effects?
Yes / No

Are there any difficulties with impairment and ECT?
Yes / No

Any changes (physically / mentally) since the last ECT?
Yes / No
Comments (if any):
Signature:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
44
Treatment 9
Consent / Capacity Review
Has the patient been asked if they have all the information they need
and whether they have any more questions or queries at each
treatment?
Yes / No
If no please specify reason why and action taken:
Is the patient confirming ongoing consent to treatment?
Yes / No
If no has consent now been withdrawn? (please specify):
Where the patient lacks mental capacity regarding ECT has this
been assessed by the RC or healthcare professional?
Yes / No
Has this assessment been documented 24 hours before treatment?
Yes / No
Does the patient have fluctuating capacity presently and in
agreement for treatment?
Yes / No
Does the Responsible Clinician plan to offer the patient with
fluctuating capacity ECT under the T6?
Yes / No
If no please advise on plan of care:
Monitoring the Patient’s Clinical Response and Cognition.
Is the patient co-operative with assessments?
Yes / No
If no how are these issues being addressed:
Please record the outcomes of the following assessment/s after
Treatment 9:
Assessment Scores
Clinical Global Impression Scale (CGI)
Any comments:
Signed:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
45
Multi-disciplinary Review
Please complete the following with the patient if possible. The reason for this is to give the
multidisciplinary team (MDT) an idea of how effective the patient thinks the treatment is
(subjective view). This is to be completed with the patient after each ECT treatment (post
ECT) and where possible signed by the patient.
The MDT also should complete the
comments at a ward round (objective view). The information is beneficial to the Lead ECT
Consultant when considering whether or not to change a treatment dose.
Treatment No 10
Patient Experience
Please circle

Do you feel / notice any improvement since starting
treatment?
Yes / No

Do others say they notice any improvement?
Yes / No

Do you think you are having side effects because of ECT?
Yes / No

After your treatment do you have any difficulty remembering
things?
Yes / No
Carer’s Comments (if any):
Comments (if any):
Patient signature:
Date:
Signature of Nurse:
Date:
Multi-Disciplinary Comments
Please circle

Have members of the MDT noticed any improvement?
Yes / No

Are any members of the MDT aware of the patient
experiencing any side effects?
Yes / No

Are there any difficulties with impairment and ECT?
Yes / No

Any changes (physically / mentally) since the last ECT?
Yes / No
Comments (if any):
Signature:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
46
Treatment 10
Consent / Capacity Review
Has the patient been asked if they have all the information they need
and whether they have any more questions or queries at each
treatment?
Yes / No
If no please specify reason why and action taken:
Is the patient confirming ongoing consent to treatment?
Yes / No
If no has consent now been withdrawn? (please specify):
Where the patient lacks mental capacity regarding ECT has this
been assessed by the RC or healthcare professional?
Yes / No
Has this assessment been documented 24 hours before treatment?
Yes / No
Does the patient have fluctuating capacity presently and in
agreement for treatment?
Yes / No
Does the Responsible Clinician plan to offer the patient with
fluctuating capacity ECT under the T6?
Yes / No
If no please advise on plan of care:
Monitoring the Patient’s Clinical Response and Cognition.
Is the patient co-operative with assessments?
Yes / No
If no how are these issues being addressed:
Please record the outcomes of the following assessment/s after
Treatment 10:
Assessment Scores
Clinical Global Impression Scale (CGI)
Hamilton Depression Rating Scale (HDRS)
Any comments:
Signed:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
47
Multi-disciplinary Review
Please complete the following with the patient if possible. The reason for this is to give the
multidisciplinary team (MDT) an idea of how effective the patient thinks the treatment is
(subjective view). This is to be completed with the patient after each ECT treatment (post
ECT) and where possible signed by the patient.
The MDT also should complete the
comments at a ward round (objective view). The information is beneficial to the Lead ECT
Consultant when considering whether or not to change a treatment dose.
Treatment No 11
Patient Experience
Please circle

Do you feel / notice any improvement since starting
treatment?
Yes / No

Do others say they notice any improvement?
Yes / No

Do you think you are having side effects because of ECT?
Yes / No

After your treatment do you have any difficulty remembering
things?
Yes / No
Carer’s Comments (if any):
Comments (if any):
Patient signature:
Date:
Signature of Nurse:
Date:
Multi-Disciplinary Comments
Please circle

Have members of the MDT noticed any improvement?
Yes / No

Are any members of the MDT aware of the patient
experiencing any side effects?
Yes / No

Are there any difficulties with impairment and ECT?
Yes / No

Any changes (physically / mentally) since the last ECT?
Yes / No
Comments (if any):
Signature:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
48
Treatment 11
Consent / Capacity Review
Has the patient been asked if they have all the information they need
and whether they have any more questions or queries at each
treatment?
Yes / No
If no please specify reason why and action taken:
Is the patient confirming ongoing consent to treatment?
Yes / No
If no has consent now been withdrawn? (please specify):
Where the patient lacks mental capacity regarding ECT has this
been assessed by the RC or healthcare professional?
Yes / No
Has this assessment been documented 24 hours before treatment?
Yes / No
Does the patient have fluctuating capacity presently and in
agreement for treatment?
Yes / No
Does the Responsible Clinician plan to offer the patient with
fluctuating capacity ECT under the T6?
Yes / No
If no please advise on plan of care:
Monitoring the Patient’s Clinical Response and Cognition.
Is the patient co-operative with assessments?
Yes / No
If no how are these issues being addressed:
Please record the outcomes of the following assessment/s after
Treatment 11:
Assessment Scores
Clinical Global Impression Scale (CGI)
Any comments:
Signed:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
49
Multi-disciplinary Review
Please complete the following with the patient if possible. The reason for this is to give the
multidisciplinary team (MDT) an idea of how effective the patient thinks the treatment is
(subjective view). This is to be completed with the patient after each ECT treatment (post
ECT) and where possible signed by the patient.
The MDT also should complete the
comments at a ward round (objective view). The information is beneficial to the Lead ECT
Consultant when considering whether or not to change a treatment dose.
Treatment No 12
Patient Experience
Please circle

Do you feel / notice any improvement since starting
treatment?
Yes / No

Do others say they notice any improvement?
Yes / No

Do you think you are having side effects because of ECT?
Yes / No

After your treatment do you have any difficulty remembering
things?
Yes / No
Carer’s Comments (if any):
Comments (if any):
Patient signature:
Date:
Signature of Nurse:
Date:
Multi-Disciplinary Comments
Please circle

Have members of the MDT noticed any improvement?
Yes / No

Are any members of the MDT aware of the patient
experiencing any side effects?
Yes / No

Are there any difficulties with impairment and ECT?
Yes / No

Any changes (physically / mentally) since the last ECT?
Yes / No
Comments (if any):
Signature:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
50
Treatment 12
Consent / Capacity Review
Has the patient been asked if they have all the information they need
and whether they have any more questions or queries at each
treatment?
Yes / No
If no please specify reason why and action taken:
Is the patient confirming ongoing consent to treatment?
Yes / No
If no has consent now been withdrawn? (please specify):
Where the patient lacks mental capacity regarding ECT has this
been assessed by the RC or healthcare professional?
Yes / No
Has this assessment been documented 24 hours before treatment?
Yes / No
Does the patient have fluctuating capacity presently and in
agreement for treatment?
Yes / No
Does the Responsible Clinician plan to offer the patient with
fluctuating capacity ECT under the T6?
Yes / No
If no please advise on plan of care:
Monitoring the Patient’s Clinical Response and Cognition.
Is the patient co-operative with assessments?
Yes / No
If no how are these issues being addressed:
Please record the outcomes of the following assessment/s after
Treatment 12:
Assessment Scores
Clinical Global Impression Scale (CGI)
Hamilton Depression Rating Scale (HDRS)
Montreal Cognitive Assessment (MoCA)
Any comments:
Signed:
Date:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
51
Treatment Centre (TC) Staff Documentation
PRE ECT ASSESSMENT (TREATMENT CENTRE / NURSING)
Patient name:
Consultant:
Date of Birth:
Inpatient (please circle)
Home Address:
History of ECT:
Outpatient (please circle)
Yes / No
Previous Date/s of ECT: Please Detail:
Last treatment course details
st
Date of 1 session
st
Telephone Number:
No of stimulations in 1
session:
Mobile Number:
Email address:
ECT dose/s at 1
Session:
Seizure Threshold:
Preferred method of Contact:
Last treatment date:
Ethnicity:
Last treatment dose:
Preferred language:
No of treatments in ECT
Course:
Previous treatment card
Obtained:
Previous ASA grade:
st
Others involved:
Dose of Induction
agent used:
Dose of Muscle relaxant
Used:
Contact details:
Contra-Indications

Cochlear implants contact Lead
ECT Consultant

MI and CVA within the last 3 months
Untreated cerebral aneurysm
Pheochromacytoma unless treated
Acute narrow angle glaucoma
Unstable IHD
Unstable C spine
Osteoporosis or fracture
Retinal detachment
Untreated heart block and CCF
Intracranial mass











Yes / No
Transfer to NGH for ECT








BMI over 35 (however some patients with BMI over over
35 may be treated at the Treatment Centre:
this is an Anaesthetic decision)
under 18
Difficult airway
Pacemaker
Myopathy
Muscular Dystrophies
Susceptibility to MH
Severe metabolic disease
Acute upper respiratory tract infection
Dental risk documented on consent form
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
52
Consent Status
Informed consent obtained, is DOH consent form completed
Yes
No
If detained, T4, T6 or T8 completed?
Yes
No
If treated under the MCA (2005) are the Mental Capacity Assessment
Yes
No
Yes
No
Guide to ECT
Yes
No
Inpatient guide to ECT
Yes
No
Outpatient guide to ECT
Yes
No
RcPsych ECT patient leaflet
Yes
No
RcPsych Depression, ECT and driving information
Yes
No
Information given about access to independent advocacy
Yes
No
Other information (please specify)
Yes
No
Yes
No
and Best Interests Checklist all completed correctly
Has the patient given permission to access system one records
Information given to patient
………………………………………………………………………………..
Reason verbal information / booklets not given
…………………………………………………………………………………
Time given to allow the patient to ask if they have all the information
they need and whether they have any more questions or queries
Prescription / Medication
Check prescription chart / in date / signed / no more than 2 prescribed
Yes
No
Check medication chart and ensure referring team Responsible Clinician
Yes
No
(RC) / delegated healthcare professional has documented current medication to
be taken / omitted on the evening prior to ECT and medication to be taken / omitted
on the morning of ECT.
Action taken
…………………………………………………………………………………
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
53
Cognitive Assessments Pre ECT
Date
Cognitive Test
Score
Hamilton Depression Rating Scale (HDRS)
Geriatric Depression Scale (GDS)
Addenbrookes Cognitive Examination – Revised (ACE-R)
Montreal Cognitive Assessment (MoCA)
Clinical Global Impression Scale (CGI)
Other assessment (please specify):
Comments:
Investigation/s
Required?
Result
Date
Checked
Detailed medical history
Physical examination
Full blood count
Biochemical profile
LFT’s
INR
HbA1c
Sickledex
Hepatitis B
Pregnancy Test
Chest x-ray
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
54
Lung Function Test
ECG
BMI
Assessments
Required?
Result
Date
Checked
Assessed
Result
Date
Checked
VTE
MUST
Manual Handling
Waterlow Ulcer
Working with risk
Carer’s Assessment
Other Considerations
Patient transport
Patient’s Medication
Level of Patient Escort
Advance Decision
Fitness to travel
Spiritual Needs
Dietary Needs
Plan – (N.B. If in any doubt contact Lead ECT Consultant / Anaesthetist).
Comments / Action Taken
Form Completed by:
Date:
Signature:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
55
Treatment Centre ECT Checklist:
Patient’s Name:
Date of Birth:
Legal Status:
Date
Patient’s identity checked
DOH consent form signed
MCA capacity assessment, Best Interest forms
Valid and relevant MHA (1983 / 2007) forms T4, T5, T6 and T8
ECT prescription chart completed in full and valid
e-PEX records / Notes and current medication chart available
Patient has fasted in line with protocol
Any make-up/ nail varnish/ hair products removed
Opportunity given to empty bladder
Patient introduced to all staff present
Patient’s orientation checked
Patient’s dentures removed
Any changes in physical health since last treatment?
(Report changes to anaesthetist)
Any side effects or problems since last treatment?
(Report details to referring team)
Day patients / confirm 24 hr. escort
Patient’s Clinical Status reviewed after each session of ECT
Signature
Patient confirming consent before each treatment (2 signatures each time; the patient and the nurse / healthcare professional confirming consent or verbal
witnessed and signed by 2 members of staff). For patients assessed using the MCA form please document the healthcare professional who completed the
assessment.
Tx 1
Signed:
Tx 1
Signed:
Tx 4
Signed:
Tx 4
Signed:
Date:
Date:
Date:
Date:
Tx 2
Signed:
Tx 2
Signed:
Tx 5
Signed:
Tx 5
Signed:
Date:
Date:
Date:
Date:
Tx 3
Signed:
Tx 3
Signed:
Tx 6
Signed:
Tx 6
Signed:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
Date:
Date:
Date:
Date:
56
Treatment Centre ECT Checklist:
Patient’s Name:
Date of Birth:
Legal Status:
Date
Patient’s identity checked
DOH consent form signed
MCA capacity assessment, DOL, Best Interest forms
Valid and relevant MHA (1983 /2007) forms T4, T5, T6 and T8
ECT prescription chart completed in full and valid
e-PEX records / Notes and current medication chart available
Patient has fasted in line with protocol
Any make-up/ nail varnish/ hair products removed
Opportunity given to empty bladder
Patient introduced to all staff present
Patient’s orientation checked
Patient’s dentures removed
Any changes in physical health since last treatment?
(Report changes to anaesthetist)
Any side effects or problems since last treatment?
(Report details to referring team)
Day patients / confirm 24 hr. escort
Patient’s Clinical Status reviewed after each session of ECT
Signature
Patient confirming consent before each treatment (2 signatures each time; the patient and the nurse / healthcare professional confirming consent or verbal
witnessed and signed by 2 members of staff). For patients assessed using the MCA form please document the healthcare professional who completed the
assessment.
Tx 7
Signed:
Tx 7
Signed:
Tx 10
Signed:
Tx 10
Signed:
Date:
Date:
Date:
Date:
Tx 8
Signed:
Tx 8
Signed:
Tx 11
Signed:
Tx 11
Signed:
Date:
Date:
Date:
Date:
Tx 9
Signed:
Tx 9
Signed:
Tx 12
Signed:
Tx 12
Signed:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
Date:
Date:
Date:
Date:
57
Treatment Centre ECT Checklist:
Patient’s Name:
Date of Birth:
Legal Status:
Date
Patient’s identity checked
DOH consent form signed
MCA capacity assessment, DOL, Best Interest forms
Valid and relevant (1983 / 2007) forms T4, T5, T6 and T8
ECT prescription chart completed in full and valid
e-PEX records / Notes and current medication chart available
Patient has fasted in line with protocol
Any make-up/ nail varnish/ hair products removed
Opportunity given to empty bladder
Patient introduced to all staff present
Patient’s orientation checked
Patient’s dentures removed
Any changes in physical health since last treatment?
(Report changes to anaesthetist)
Any side effects or problems since last treatment?
(Report details to referring team)
Day patients / confirm 24 hr. escort
Patient’s Clinical Status reviewed after each session of ECT
Signature
Patient confirming consent before each treatment (2 signatures each time; the patient and the nurse / healthcare professional confirming consent or verbal
witnessed and signed by 2 members of staff). For patients assessed using the MCA form please document the healthcare professional who completed the
assessment.
Tx no
Signed:
Tx no
Signed:
Tx no
Signed:
Tx no
Signed:
Date:
Date:
Date:
Date:
Tx no
Signed:
Tx no
Signed:
Tx no
Signed:
Tx no
Signed:
Date:
Date:
Date:
Date:
Tx no
Signed:
Tx no
Signed:
Tx no
Signed:
Tx no
Signed:
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
Date:
Date:
Date:
Date:
58
Day Patient ECT Form.
Information given to patient
Introduction to ECT ................................................................................. Yes / No
Out-patient ECT booklet............................................................................ Yes / No
Date of first treatment................................................................................ Yes / No
Directions to ECT department................................................................... Yes / No
Fasting times explained ............................................................................ Yes / No
Supervising Adult leaflet……….................................................................. Yes / No
Expectations of escort/carer discussed..................................................... Yes / No
Driving Leaflet…………………………………………………………………. Yes / No
Information given by: ..........................................................................
.............................................................................................................
Patient agreement
I confirm that I will arrange for a responsible adult to accompany me home and stay with
me for at least 24 hours.
As discussed with my RC / Healthcare professional I agree not to drive for the duration of
my ECT treatment. I understand that if I do so, I may be considered unfit to drive. I also
understand that it may affect my insurance cover.
I am aware that I should not have sole responsibility for the care of children, operate
machinery, drink alcohol, or sign any financial or legally binding documents within 24
hours of my ECT treatment.
Patient’s signature:.................................................................
Date.......................
Witness signature:.................................................................
Date........................
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
59
Treatment 1 - I confirm that I have read and understood the following guidelines
Signed:……………………………………
Patient:…………………
Date:……………………..
Time:…………………
Date:…………………..
Carer:…………………………….
Discharged by:………………….
Treatment 2 - I confirm that I have read and understood the following guidelines
Signed:……………………………………
Patient:…………………
Date:……………………..
Time:…………………
Date:…………………..
Carer:…………………………….
Discharged by:………………….
Treatment 3 - I confirm that I have read and understood the following guidelines
Signed:……………………………………
Patient:…………………
Date:……………………..
Time:…………………
Date:…………………..
Carer:…………………………….
Discharged by:………………….
Treatment 4 - I confirm that I have read and understood the following guidelines
Signed:……………………………………
Patient:…………………
Date:……………………..
Time:…………………
Date:…………………..
Carer:…………………………….
Discharged by:………………….
Treatment 5 - I confirm that I have read and understood the following guidelines
Signed:……………………………………
Patient:…………………
Date:……………………..
Time:…………………
Date:…………………..
Carer:…………………………….
Discharged by:………………….
Treatment 6 - I confirm that I have read and understood the following guidelines
Signed:……………………………………
Patient:…………………
Date:……………………..
Time:…………………
Date:…………………..
Carer:…………………………….
Dicharged by:………………….
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
60
Treatment 7 - I confirm that I have read and understood the following guidelines
Signed:……………………………………
Patient:…………………
Date:……………………..
Time:…………………
Date:…………………..
Carer:…………………………….
Discharged by:………………….
Treatment 8 - I confirm that I have read and understood the following guidelines
Signed:……………………………………
Patient:…………………
Date:……………………..
Time:…………………
Date:…………………..
Carer:…………………………….
Discharged by:………………….
Treatment 9 - I confirm that I have read and understood the following guidelines
Signed:……………………………………
Patient:…………………
Date:……………………..
Time:…………………
Date:…………………..
Carer:…………………………….
Discharged by:………………….
Treatment 10 - I confirm that I have read and understood the following guidelines
Signed:……………………………………
Patient:…………………
Date:……………………..
Time:…………………
Date:…………………..
Carer:…………………………….
Discharged by:………………….
Treatment 11 - I confirm that I have read and understood the following guidelines
Signed:……………………………………
Patient:…………………
Date:……………………..
Time:…………………
Date:…………………..
Carer:…………………………….
Discharged by:………………….
Treatment 12 - I confirm that I have read and understood the following guidelines
Signed:……………………………………
Patient:………………… Date:……………………..
Carer:…………………………….
Discharged by:………………….
Time:…………………
Date:…………………..
ECT Pack, Berrywood Hospital Treatment Centre, Northamptonshire Healthcare Foundation Trust
Review Date: April 2018
61