"Seizure Report Flow Chart Template" - United Kingdom

ADVERTISEMENT
ADVERTISEMENT

Download "Seizure Report Flow Chart Template" - United Kingdom

Download PDF

Fill PDF online

Rate (4.4 / 5) 20 votes
Seizure Report Flow Chart
Name of Patient:_____________________________ Sex: _________
Date of Birth:________________________________ Age:_________
Date of each seizure
Time of onset
Total time involved
OBSERVATION BEFORE SEIZURE
Cries out
Other
OBSERVATION DURING SEIZURE
Extremity involvement:
Both upper and lower
Right
Arms affected
Left
Right
Legs affected
Left
Straight
Bent
Stiff
Limp
Before
Verbal sounds:
During
Face twitching:
Mouth:
Open
Closed
Grimacing
Drooling:
Vomited:
Staring
Eye movement:
Open
Closed
Fluttering
Rolled back
Turned right
Head:
Turned left
Turned down
Hyper extended back
Nodding
Rigid
Body-trunk
Limp
Sitting
Seizure Report Flow Chart
Name of Patient:_____________________________ Sex: _________
Date of Birth:________________________________ Age:_________
Date of each seizure
Time of onset
Total time involved
OBSERVATION BEFORE SEIZURE
Cries out
Other
OBSERVATION DURING SEIZURE
Extremity involvement:
Both upper and lower
Right
Arms affected
Left
Right
Legs affected
Left
Straight
Bent
Stiff
Limp
Before
Verbal sounds:
During
Face twitching:
Mouth:
Open
Closed
Grimacing
Drooling:
Vomited:
Staring
Eye movement:
Open
Closed
Fluttering
Rolled back
Turned right
Head:
Turned left
Turned down
Hyper extended back
Nodding
Rigid
Body-trunk
Limp
Sitting
Laying
Trembling
Jerking
Standing
Pale
Skin color
Grey
Blue
Red (flushed)
Difficulty during
Breathing
Difficulty after
15 seconds
Longer (amount ?)
Urine
Incontinent:
Bowels
OBSERVATION AFTER SEIZURE
Drowsy
Confused
Sleep (length of time)
Injury (elaborate)
Other:
School nurse called
Health clerk called
Parent called
Doctor called
911 called
Responder initials
Page of 2