NASO-GASTRIC DRAINAGE TUBE INSERTION AUTHORISATION
This form MUST be signed by the CLINICIAN at the time the decision is made for NG insertion
Consultant ……………………….
Patient name, hospital number, DOB
(use label)
Date ………………………………...
Ward ……………..
An NG tube should be inserted IMMEDIATELY if there is Clinical or Radiological
suspicion of obstruction
Date and time decision made for NG insertion: ……………………………………………….
Decision made by: Print name …………………………………………………………………..
Signature ……………………………………………………………………
Designation: ………………………………………………………………..
(NOT to be signed ‘on behalf of’ – must be by the decision maker)
Name of Nurse asked to insert NG ………………………………………. Time ………………
Patient agrees to insertion 
Patient declines insertion 
Date and time NG inserted: …………………………………. Number of attempts:...............
Inserted by: Print name ……………………………………………………………………………..
Signature ………………………………………………………………………………
Designation: ………………………………………………………………………….
NG Size: ……………………………. Expiry Date: ……………………………
Aspirate amount: ………………….
Aspirate Ph: …………………………. (if Ph <5 chest x-ray not required)
Chest x-ray performed
Yes 
No 
Reviewed by: Print name …………………………………………………………………..
Signature ……………………………………………………………………
Designation: …………………………………………………………………
V6 Ruth Peacock/Simon Ward - Approved at SQS 17/11/15