Appendix 1: Approach to a Normal EEG Report

Appendix 1: Approach to a Normal EEG Report

Appendix 1: Approach to an EEG Report.

UNC EEG REPORT: {EEG title:29647}

Patient: @NAME@

Date of Birth: @DOB@

UNC MRN: @MRN@

Ordering Provider: @REFERPROV@

Identifiers: Patient and referring provider. If there is no referring provider, let staff know to manually fax the report.

Study Information

Duration of the study has implications to the billing of the study.

Date of Study: ***

EEG Start: ***

EEG End: ***

HISTORY: Per chart, @NAME@ is @AGE@ years old @SEX@ with ***

INDICATION: {eeg; indication for procedure:85577}

History/Indication: a brief recapitulation that describes the clinical question that this EEG is meant to answer.

PATIENT STATE: {SML Patient State :74330}

PERTINENT MEDICATIONS: {seizure medications: 93165}

The medications need to be documented because there are certain medications that can affect the EEG and may explain a particular finding, especially seizure medications.

TECHINCAL DESCRIPTION

Routine EEG was performed while awake utilizing 21 active electrodes placed according to the international 10-20 system. The study was recorded digitally with a bandpass of 1-70Hz and a sampling rate of 200Hz and was reviewed with the possibility of multiple reformatting.

The first sentence describes the technical aspects of the EEG. It describes what electrodes were placed and if there were any technical difficulties. For example, patients who have just had a craniotomy, some electrodes need to be moved because of the incision.

EEG FINDINGS

The description of the EEG Findings should be detailed enough to allow another clinical neurophysiologist to picture the EEG without opening the study.

Background:

{UNC EEG background without sleep:110332}

The next statement describes the general background of the patient. For a normal EEG we typically describe the normal organization and the posterior dominant rhythm and reactivity. The clinical state if the patient is not normal.

Sleep:

{UNC EEG Sleep:110331}

What states were captured during the EEG as there are EEG findings that are seen predominantly during sleep. Describe the sleep transients that were observed and whether they were appropriate for stated age. Some findings occur during sleep.

Focal Features:

There {Actions; were/were no:19617} focal slowing or interhemispheric asymmetries. Describe whether there are any focal features or epileptiform discharges. Location, frequency, morphology

Epileptiform Activity:

There {Actions; were/were no:19617} epileptiform abnormalities

Activating Procedures:

{eeg hyperventilation:96586}

{photo stim:96587}

Activation procedures are also described such as hyperventilation or photic stimulation which may promote certain EEG findings. We restrict the use of hyperventilation in patients over the age of 70 and if they have cardiopulmonary disease, cerebrovascular disease or if they are pregnant.

Ictal Activity:

{UNC ictal patterns:121894}

Clinical Events:

{UNC ictal patterns:121894}

Single channel EKG:

{Desc; regular/irreg:14544::"regular"} rhythm and normal rate

EEG SUMMARY

{Normal/Abnormal:58117} {PROCEDURE - EEG STATE:18081} EEG:

For EEGs with any unusual or pathologic findings, the deliniates the EEG findings of interest

CLINICAL CORRELATION

This routine EEG is {normal/abnormal/---:49231}. There were no seizures or epileptiform activity.

The clinical correlation draws together the history and EEG results for a clinical conclusion.

{EEG comments:71738} It develops a clinical interpretation of those findings and their relationship to possible underlying disease states.

Description of waveforms:

Discharges:

Localization:

Focal:

Field

Generalized

Diffuse

Polarity (negative, positive or horizontal)

Voltage

Frequency

Rare: < 1/hour

Occasional >1/ hour but less than 1/min

Frequent: > 1/min but less than 1/sec

Morphology

Sharp waves+/- slow wave

Spikes

Polyspike

Activation:

Hyperventilation

Photic stimulation

Accentuation with sleep

Clinical correlation

Context:

Accompanied by slowing?

Slowing:

Localization:

Focal:

Regional

Hemispheric

Diffuse

Voltage:

Very low: <20 microvolts

Low: 20-49 microvolts

Medium: 50-199 microvolts

High: >200 microvolts

Frequency:

Theta or delta

+/- superimposed faster frequencies

Morphology:

Polymorphic

Monomorphic

Continuity:

Continuous

Intermittent

Reactivity:

State changes

Spontaneous

Stimulation