Appendix 1

ECT Work-Up Checklist

This section to be completed by referring team

Patient Details:

Surname: / Ward/Dept:
First Name: / Consultant:
Title (Mr/Mrs/Miss/Ms): / Age:Sex:
DOB: / Patient NHS No:
Telephone
Address
Diagnosis
Proposed start date for ECT
Date work-up checklist completed
Medication at start of treatment (and implications for ECT):
Specify drug, dose, when commenced (include prn)
1
2
3
4
5
6
7
8
9
(a) Consider potential effect of drugs on seizure threshold?
(b) Possible interaction with anaesthetic agents?
Medical / Surgical History
Has patient had any previous courses of ECT? If so, detail here and ensure that previous records are available
Has patient any known allergies (including medication)
Has Junior Doctor recorded ASA Grade? (3 and above requires anaesthetic opinion)
Does the patient have a cochlear implant? (this is a contraindication for ECT)
Does the patient have a pacemaker? Has a pre treatment check been performed?
Does the patient have an implanted defibrillator?Has this treatment been discussed with cardiologist?
Note any history of gastric reflux/hiatus hernia, etc
Any other comments relevant to referral
Information Provision / Yes / No / Comment
●Local ECT Leaflet /  / 
●NICE ECT Leaflet /  / 
●Mental Health Act Commission Leaflet Patient Information for Detained Patients /  / 
●ECT DVD /  / 
●Any other information required by patient /  / 
●Tour of ECT Department /  / 

ECT Work-Up Clinic

Physical Tests/Details (discuss with anaesthetist which tests are necessary).

Results of all tests must be available for scrutiny at ECT sessions, and any abnormalities discussed in advance with ECT team.

Blood Tests / Yes / No / Date / Details / Results
●U andE /  / 
●FBC /  / 
●Other (please state) /  / 
●ECG /  / 
●Chest Xray /  / 
●Other /  / 
●Oral/dental Examination /  / 
●Alcohol / Drug Abuse /  / 
●Smoker /  / 
●Pregnant /  / 
●Epileptic /  / 
●HIV Positive /  / 
●Hepatitis /  / 
●Urinalysis /  / 
  • VTE Assessment relevant to ECT
referral where required /  / 
Additional Information i.e. protective medication/any special dietary requirements
Has patient been informed not to bring valuables to the ECT department
Mood Rating Scale Outcome Score: (Montgomery & Asberg Depression Rating Scale [MADRs] recommended
Documentation from Referrer
Yes / No / N/A / Details
●Prescription completed /  / 
●Consent form completed /  / 
●MHA Documentation completed /  /  / 
●Capacity assessed /  /  / 
  • Previous ECT documentation
/  /  / 
●Physical Examination and form completed
Signature of person
completing Section 1

Northumberland, Tyne and Wear NHS Foundation Trust

Appendix 1 – ECT Work-Up Checklist and Work-Up Clinic– V03 - Issue 1 – Issued Apr 16

Part of ECT-PGN-01-Integrated care pathway for source Electro-Convulsive Therapy -NTW(C)51-ECT Policy