Dix-Hallpike and Canalith Repositioning Maneuver Procedure Note

Date/Time: [Date and time of procedure]

Clinician: [Clinician name and credentials]

Location: [Clinic/ED/inpatient bedside location]

(If diagnostic testing was performed without a therapeutic maneuver, omit the Canalith Repositioning Maneuver and Post-Maneuver Assessment sections. If the Supine Roll Test was not performed, omit that section entirely. For Dix-Hallpike findings, if a side was not tested, state "Not performed" with reason. Document nystagmus exactly as observed; do not infer canal localization without supportive nystagmus direction. If visualization was limited, explicitly note this in the interpretation.)

Procedures Performed

(List which diagnostic tests were done and any therapeutic maneuvers, with laterality and number of cycles. If a test was not performed, document the reason.)

• Diagnostic testing: [Dix-Hallpike right / left / bilateral / not performed with reason]; [Side-lying alternative test with side and reason if used]; [Supine roll test if performed]
• Therapeutic maneuvers: [Maneuver name, side treated, number of cycles] (State "None" if no therapeutic maneuver performed.)

Indication

[Clinical reason for testing] (Include triggering positions, typical episode duration in seconds vs minutes, associated symptoms such as nausea or hearing changes, and relevant history of prior episodes or response to prior maneuvers. Keep brief; do not duplicate full HPI if documented elsewhere.)

Pre-Procedure Assessment

• Contraindication screen: [Screened negative / Positive findings with adaptations made] (Address cervical spine concerns, back limitations, and vascular concerns.)
• Baseline symptoms at rest: [Baseline dizziness, nausea, or other pertinent symptoms]
• Preparation and consent: [Patient counseled on expected vertigo and nausea; emesis precautions in place; assistance and guarding arranged; verbal consent obtained]
• Visualization method: [Direct observation / Frenzel lenses / Video goggles] (Note if visualization was limited and how this affects interpretation.)

Dix-Hallpike Testing

(If a side was not tested, state "Not performed" with reason.)

Right Dix-Hallpike

• Symptoms: [Subjective vertigo: present / absent; severity; associated nausea]
• Nystagmus: [Present / Absent / Uncertain] (If present, describe torsional component with clock direction, vertical component as upbeating or downbeating, horizontal component if present, latency in seconds, duration, fatigability, and reversal on sitting.)
• Interpretation: [Negative / Consistent with posterior canal BPPV / Horizontal canal pattern / Atypical or concerning for central / Indeterminate with reason]

Left Dix-Hallpike

• Symptoms: [Subjective vertigo: present / absent; severity; associated nausea]
• Nystagmus: [Present / Absent / Uncertain] (If present, describe torsional component with clock direction, vertical component as upbeating or downbeating, horizontal component if present, latency in seconds, duration, fatigability, and reversal on sitting.)
• Interpretation: [Negative / Consistent with posterior canal BPPV / Horizontal canal pattern / Atypical or concerning for central / Indeterminate with reason]

Side-Lying Positional Test (Include only if used instead of or in addition to standard Dix-Hallpike.)

• Side and reason for alternative: [Side tested and clinical reason alternative method was required]
• Symptoms: [Subjective vertigo: present / absent; severity; nausea]
• Nystagmus: [Present / Absent / Uncertain] (Describe direction, latency, duration, fatigability, reversal.)
• Interpretation: [Negative / Consistent with posterior canal pattern / Horizontal canal pattern / Atypical or concerning for central / Indeterminate]

Overall Interpretation

[Concise localization statement] (Example: "Findings consistent with right posterior canal BPPV, canalithiasis pattern." If nystagmus not visualized but symptoms are positional, state "Subjective positional vertigo without observable nystagmus" and note limitations. If pattern is atypical or concerning for central pathology, explicitly state concern and escalation plan.)

Supine Roll Test

(Include this section only if performed.)

Head turn to the right:

• Symptoms: [Vertigo provoked: yes / no; severity; nausea]
• Nystagmus: [Geotropic / Apogeotropic / Absent; intensity]

Head turn to the left:

• Symptoms: [Vertigo provoked: yes / no; severity; nausea]
• Nystagmus: [Geotropic / Apogeotropic / Absent; intensity]

Interpretation: [Lateral canal involvement assessment; suspected affected side based on stronger response and nystagmus pattern]

Canalith Repositioning Maneuver

(Include this section only if a therapeutic maneuver was performed.)

Maneuver: [Epley / Semont / BBQ roll / Gufoni / Other], [side treated], [number of cycles] (Note rationale if not obvious from interpretation; describe any modifications such as limited neck extension, pillow use, or side-lying variant.)

Technique: [Standard sequence performed with each position held approximately 30 seconds or until nystagmus resolved] (For atypical cases or teaching documentation, optionally include position-by-position findings.)

Tolerance: [Well tolerated / Nausea / Emesis / Vasovagal symptoms / Pain / Anxiety / Unable to complete with reason and actions taken]

Post-Maneuver Assessment

(Include this section only if a therapeutic maneuver was performed.)

• Repeat positional testing: [Repeat Dix-Hallpike results] (Preferred method of assessment.)
• Subjective symptom change: [Resolved / Improved / Unchanged / Worse] (Do not claim resolution without supporting evidence.)
• Gait and stance assessment: [Stable / Mildly unsteady / Ataxic / Requires assistance]

Complications

[None / Specific complications] (If complications occurred, document emesis, syncope or presyncope, neck pain, suspected canal conversion, persistent atypical nystagmus, new neurologic symptoms, or other adverse events. Include escalation plan if atypical findings occurred.)

Counseling and Follow-up

Safety precautions: [Counseling provided regarding hazardous activities, assisted ambulation needs, home support arrangements]

Post-procedure restrictions: [Specific positional restrictions recommended / No postural restrictions recommended per current guidelines] (State explicitly what was recommended.)

Follow-up: [Expected course, possibility of recurrence, follow-up timeframe and provider, instructions if symptoms persist or recur]

Return precautions: [Red flags discussed: new focal neurologic deficit, severe headache, persistent non-positional vertigo, new hearing loss, syncope]