Healthcare Seizure Protocol

HEALTHCARE SEIZURE PROTOCOL

Patient Identification

Patient Name:

Date of Birth:    Gender:

Insurance / Responsible Party

Medical & Seizure History

Seizure Diagnosis / Type (select all that apply):
Focal   Generalized tonic‑clonic   Absence   Atonic   Myoclonic   Unknown

Typical seizure frequency:    Typical duration:

Does the patient experience auras or warning signs?

Flashing lights / visual patterns   Sleep deprivation   Alcohol / substance use   Stress / illness   Missed medication   Other:

Seizure Response Protocol

The following outlines steps to be followed by clinical staff, caregivers, and authorized personnel when the patient experiences a seizure. Staff are authorized to follow this protocol until relieved by higher medical authority or emergency responders.

Immediate actions during a seizure:

• Protect the patient from injury (clear surrounding area; cushion head).
• Maintain airway and observe breathing; do not restrain limbs unless necessary for safety.
• Do not place objects in the patient's mouth.
• Note start time of seizure and document observations.

Administer rescue medication if indicated below:

Authorization to administer rescue medication: I authorize trained staff to administer the rescue medication listed above according to these instructions and per standing medical orders.

Thresholds for escalation:

Call emergency medical services (911 or local emergency number) if seizure continues longer than minutes from observed start, or if multiple seizures occur without full recovery between events.

Call emergency medical services immediately if any of the following occur: respiratory compromise, cyanosis, hypoxia, persistent altered consciousness after seizure, head injury, pregnancy, or if directed by supervising clinician.

Documentation & Communication

Staff will document seizure start and stop times, observed behaviors, interventions rendered (including medication name, dose, route, time), and the patient's response. A copy of the incident report will be provided to the patient's primary clinician and the emergency contact listed above as permitted by privacy regulations.

Authorization, Acknowledgment, and Legal Terms

I, the undersigned, authorize the healthcare facility and its authorized personnel to implement the Seizure Protocol described above, including administration of the listed rescue medication when indicated. I acknowledge that the protocol is based upon current orders and available information and that staff will exercise clinical judgment when applying the protocol to an acute event.

I understand and agree that:

• This protocol does not replace ongoing medical care and should be reviewed with the prescribing clinician.
• I may revoke this authorization at any time by providing written notice to the facility, except to the extent that actions have already been taken in reliance on this authorization.
• The facility and staff will act in good faith and in accordance with standard medical practices when implementing this protocol. I release the facility and its employees from liability for actions taken in accordance with this protocol, except where negligence or willful misconduct is proven.

Authorization expiration date:    If left blank, this authorization remains in effect until rescinded in writing or until the patient's care episode concludes.

Privacy & Release of Information

By signing below, I acknowledge that the information contained in my medical record related to seizure events and treatment may be disclosed to emergency responders and the emergency contact named above as necessary for treatment and continuity of care. I understand my rights to privacy and that disclosures will be limited to the minimum necessary for treatment, payment, or healthcare operations.

Provider / Clinic Use Only

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