Endocrine Stimulation Test Procedure Note (ACTH/GH/GnRH)

Date of Service: [Date]

Start Time / End Time: [Start time] / [End time]

Location: [Location]

Patient Name: [Full name]

MRN: [Medical record number]

DOB: [Date of birth]

Weight (kg): [Weight in kg] (Use value measured on test day.)

Ordering Clinician: [Name, credentials]

Performing Clinician(s): [Name(s), credentials, and role(s)]

Test(s) Performed

• [Test name: ACTH stimulation / GH stimulation / GnRH or GnRH-agonist stimulation] — Agent: [cosyntropin / arginine / clonidine / glucagon / insulin (ITT) / GnRH / leuprolide / triptorelin / other: specify]
• [Additional test if applicable] — Agent: [specify] (If multiple tests performed sequentially, list in order conducted.)

Indication

[Clinical question the test is intended to answer] (Include only context that directly affects test selection, safety, or interpretation—relevant endocrine history, comorbidities affecting risk such as diabetes, seizure disorder, or cardiovascular disease, current therapies that may interfere such as glucocorticoids, estrogen, or GH therapy, and baseline findings that motivated testing.)

Pre-Test Assessment

• Fasting status: [Fasted / Non-fasted] — Last caloric intake at [clock time]
• Baseline vitals: BP [value] at [time]; HR [value] at [time]
• Baseline POC glucose: [value] at [time] (Include if relevant to the protocol.)
• Recent glucocorticoid use: [Drug, dose, route, last dose time / None] (Include if applicable.)
• Contraindication screen: [Agent-specific findings documented] (For ITT: confirm no seizure disorder or significant cardiovascular disease. For clonidine: document baseline BP and supervision plan. For GnRH testing in females of reproductive age: document pregnancy test result if performed per protocol.)
• Emergency supplies: [Confirmed available / specify items]

Consent

Informed consent obtained from [patient / parent/guardian] on [date/time]. [Summary of discussion including purpose, expected duration, and agent-specific risks explained] (Tailor risks to agent: hypotension/somnolence for clonidine; nausea for glucagon/arginine; hypoglycemia symptoms for ITT.) Patient/guardian verbalized understanding and agreed to proceed. (If separate consent form used, reference its location.)

Procedure Details

• Vascular access: [Peripheral IV / central line] — Site: [anatomic site], Laterality: [left / right], Gauge: [size]
• Baseline specimens drawn: [Yes / No] at [clock time] — Analytes: [list]
• Agent(s) administered:
  • [Agent name]: [dose with units and weight basis] (Max cap: [value] if applied.) Route: [IV bolus / IV infusion / IM / SC / PO]. Time: [clock time or start–stop for infusion]
  • (Add entry for each agent used.)
• Sampling schedule:
  • [Timepoint, e.g., Baseline / +30 min / +60 min]: Planned [interval] — Actual draw [clock time] — Analytes: [cortisol / ACTH / GH / glucose / LH / FSH / other]
  • (Repeat for each protocol timepoint.)
• Sample integrity issues: [None / Describe: timepoint affected, reason, whether recollected, expected impact on interpretation]

Monitoring Record

Timepoint	Clock Time	Action	Vitals (BP/HR)	POC Glucose	Symptoms
[Baseline / +X min]	[hh:mm]	[Agent given / blood draw / glucose check]	[BP/HR]	[value or N/A]	[Reported/observed symptoms or none]
(Add row for each protocol timepoint.)

Adverse Events

[Description of event(s): onset time, objective findings (BP/HR/glucose/symptoms), severity, intervention (medication/dose/route/time), response, and whether protocol was continued, modified, or stopped]

(If none occurred, state: "No adverse events or complications observed during testing.")

Protocol Completion

[Completed as planned / Deviations occurred: specify] (If deviations, describe: missed sample, timing variance, dose modification, early termination, patient refusal, or safety stop—and whether deviation may limit interpretation. Note if ordering clinician was notified.)

Post-Test Status and Disposition

• Final vitals: BP [value] at [time]; HR [value] at [time]
• Final POC glucose: [value] at [time] (Include for hypoglycemia-risk protocols.)
• Observation period: [Duration] (If required by protocol.)
• IV access: Removed at [time] — Site condition: [hemostasis achieved / dressing applied / no complications]
• Disposition: [Discharged home / transferred / admitted] — Escort: [required / not required]
• Post-test instructions: [Resume normal diet; emphasize prompt meal after hypoglycemia-risk protocols] [Activity restrictions, e.g., no driving after clonidine until somnolence resolves] [Return precautions: syncope, persistent vomiting, severe weakness, confusion]

Results Plan

• Analytes sent: [List tests ordered across timepoints]
• Expected turnaround: [Timeframe if known]
• Interpretation: [Ordering clinician / Endocrinology service] will interpret using laboratory assay-specific reference ranges and established cutoffs appropriate to patient's age, sex, and protocol.
• Patient notification: [Phone / portal message / follow-up visit] within [timeframe]
• Pending information: [Specify items pending; addendum will be added when available] (Do not infer or estimate safety-critical details such as fasting status, medication timing, administered doses, achieved glucose nadir, or rescue medications.)