11/13/24, 7\:41 PM Guide | Documenting an ECG

Documenting an ECG

Table of contents

Introduction

In addition to knowing how to record and interpret an ECG, it's also important to understand how to document an ECG in a
patient's notes. This guide provides a structured approach to ECG documentation.

Documentation basics

Before we discuss how to document an ECG, we need to cover the basics that apply to all documentation in a patient’s notes.
You can check out our detailed guide to writing in the notes for more information.

What should I use to write with?

You need to use a pen with black ink, as this is the most legible if notes are photocopied.

Patient details

relevant patient\:
For every new sheet of paper (including the ECG itself) your
Full name
Date of birth
Unique patient identi
Home address
If a patient label containing at least three identi
manually.

Location details

You should indicate the patient’s current location on the continuation sheet\:
Hospital
Ward
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Patient identi

Beginning your entry

At this point, you should already be holding a pen with black ink and you should have ensured the continuation sheet has at
least three key patient identi
The next documentation steps include\:
1. Adding the date and time (in 24-hour format) of your entry.
2. Writing your name and role as an underlined heading.
3. Adding your entry in the notes below this heading (see the next section for details).
Starting your entry in the notes
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Documenting the ECG results

1. Document the time and date that the ECG was performed as this may be signi
documenting.
2. Write the indication for the ECG (e.g. chest pain, tachycardia).
3. Document your interpretation of the ECG (see our guide to interpreting an ECG)\:
Rate
Rhythm
Axis
P waves
PR interval
QRS complex
QT interval
ST-segment
T waves
4. Document your overall impression of the ECG (e.g. ST-elevation myocardial infarction).
5. Document your plan based on the ECG
Documenting ECG results

Completing the entry

At the end of your entry to need to include the following\:
Your full name
Your grade/role (e.g. F2/Medical Registrar)
Your signature
Your professional registration number (e.g. GMC number)
Your contact number (e.g. phone/bleep)
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Source\: geekymedics.com
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