EMG/Nerve Conduction Study Report (Pediatric)

Report Title: EMG/Nerve Conduction Study Report - Pediatric [Body region if applicable]

Patient Name: [Patient name]

MRN: [Medical record number]

DOB: [Date of birth]

Age at Study Date: [Age in years and months]

Sex: [Sex]

Height: [Height with units]

Weight: [Weight with units]

Referring Clinician: [Referring clinician name and specialty]

Study Date: [Study date]

Location: [Facility/location]

Interpreting Physician: [Physician name, degrees, board certifications]

(Omit any identifier not documented rather than marking as unknown.)

Clinical Information

Reason for Referral: [Specific clinical statement and question to be answered] (State clearly; avoid listing only a diagnosis code.)

Relevant History: [Focused history relevant to test selection] (Include onset, duration, distribution, symptom type, functional impact, pertinent comorbidities. Document any limitations in available history.)

Relevant Examination: [Focused examination findings relevant to localization] (Summarize strength patterns, reflexes, sensory distribution, atrophy, tone, or gait findings that guided study selection.)

Prior Electrodiagnostic Studies: [Date and key findings if available] (Note interval changes if known. Omit if none.)

Study Conditions

• Temperature Monitoring: [Limb temperatures monitored and maintained within target ranges, or document actual values] (Typical targets: hands 32–36°C, feet 30–36°C.)
• Cooperation and Tolerance: [Cooperation level; whether child life specialist and/or parent/guardian was present; whether tolerance limited study scope]
• Sedation/Analgesia: [Agents used, if any] (Document if could affect volitional activation. Omit if none.)
• Reference Values: [State that pediatric age-stratified norms were applied; cite source if applicable]
• Precautions/Contraindications: [Bleeding risk, implantable devices, skin integrity issues] (Omit if none.)

(If routine without limitations: "Study performed under standard conditions with adequate warming and cooperation; pediatric normative values applied.")

Nerve Conduction Studies

Technique: [Measurement conventions used] (Note latency measurement method, amplitude conventions, and that pediatric age-stratified reference values were applied.)

Technical Limitations: [NCS-specific limitations] (Submaximal stimulation, movement artifact, low tolerance to stimulation, inadequate warming. State "None" if routine.)

Sensory NCS

Side	Nerve	Stimulation Site	Recording Site	Amplitude (µV)	Latency (ms)	Conduction Velocity (m/s)	Normal/Abnormal	Comments
[L/R]	[Nerve]	[Stim site]	[Record site]	[Value or NR]	[Value or NR]	[Value if calculated]	[normal / abnormal / borderline]	[Notes]

(Add row for each sensory study performed. Enter "NR" for absent responses.)

Motor NCS

Side	Nerve	Stimulation Sites	Recording Muscle	Distal Latency (ms)	Amplitude (mV)	Conduction Velocity (m/s; segment)	Normal/Abnormal	Comments
[L/R]	[Nerve]	[Sites]	[Muscle]	[Value or NR]	[Value or NR]	[Value(s) with segment]	[normal / abnormal / borderline]	[Notes; include conduction block/temporal dispersion if present]

(Add row for each motor study. Enter "NR" for absent responses.)

Late Responses

(Include only if performed.)

Side	Nerve/Muscle	F-wave Minimum Latency (ms)	H-reflex Latency (ms)	Normal/Abnormal	Comments
[L/R]	[Nerve/Muscle]	[Value or NR]	[Value or NR]	[normal / abnormal / borderline]	[Notes]

Repetitive Nerve Stimulation

(Include only if performed.)

Side	Nerve/Muscle	Condition	Stimulation Rate (Hz)	Baseline Amplitude	Decrement/Increment (%)	Normal/Abnormal	Comments
[L/R]	[Nerve/Muscle]	[rest / post-exercise / post-activation]	[Hz]	[Value]	[Value]	[normal / abnormal / borderline]	[Notes]

Needle EMG

Technique: [Needle type and grading conventions used]

Technical Limitations: [EMG-specific limitations] (Limited voluntary activation, pain-limited exam, muscles not sampled due to tolerance or positioning. State "None" if routine.)

Side	Muscle	Insertional Activity	Spontaneous Activity	MUAP Morphology	Recruitment Pattern	Comments
[L/R]	[Muscle name]	[normal / increased / decreased]	[fibs/PSWs/fasciculations/other or none]	[Describe or "not assessable—limited activation"]	[normal / reduced / early / incomplete activation]	[Notes]

(List each muscle examined by name. Do not use summary statements without naming muscles.)

Summary and Interpretation

Findings Summary: [Brief summary of NCS and EMG findings using standardized terms] (e.g., low amplitude, prolonged distal latency, conduction slowing, absent response, conduction block, temporal dispersion, active denervation, chronic reinnervation changes.)

• Overall Result: [normal / abnormal / technically limited]
• Electrophysiologic Diagnosis/Localization: [root / plexus / peripheral nerve and segment / neuromuscular junction / muscle]
• Laterality and Distribution: [focal / multifocal / generalized; specify side(s)]
• Pathophysiology: [axonal / demyelinating / mixed; sensory vs motor; conduction block or temporal dispersion] (Include only if supported by data.)
• Severity: [mild / moderate / severe] (Anchor to specific findings. Include only if abnormal.)
• Chronicity/Activity: [active denervation / chronic reinnervation / acute-on-chronic / indeterminate] (Include only if supported.)
• Comparison to Prior Study: [Interval change with date] (Include only if prior study available.)
• Limitations Affecting Interpretation: [How limitations affect diagnostic certainty] (Omit if none.)

(Acceptable: electrophysiologic localization directly supported by data. Do not infer clinical symptoms or diagnoses beyond what electrophysiology supports. Label any suggested clinical diagnosis as "clinical correlation.")

Clinical Correlation and Recommendations

Correlation: [Statement of whether findings explain the referral question]

Recommendations: [Imaging, laboratory/genetic testing, neuromuscular ultrasound, repeat electrodiagnostic testing as indicated] (Include timeframe if repeat study recommended. Omit if no actionable recommendations.)

Urgent Communication: [Who was notified and when] (Include only if urgent or unexpected findings required immediate communication.)

Interpreting Physician: [Name, degrees, certifications]

Signature: ________________________________

Date of Interpretation: [Date]

Technologist: [Name, credentials] (Include only if applicable.)

Trainee: [Name, role] (Include only if applicable.)