How to Document an ECG in the Notes

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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

For every new sheet of paper (including the ECG itself) your first task should be to document at least three key identifiers for the relevant patient:

  • Full name
  • Date of birth
  • Unique patient identifier
  • Home address

If a patient label containing at least three identifiers is available, then this can be used instead of writing out the information manually.

Location details

You should indicate the patient’s current location on the continuation sheet:

  • Hospital
  • Ward
    Patient identifiers
    Patient identifiers

    Patient identifiers


Beginning your entry in the notes

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 identifiers at the top.

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).

Beginning an entry
Beginning an entry

Documenting the ECG results in the notes

1. Document the time and date that the ECG was performed as this may be significantly different from the time you are 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 findings.

Documentation example
Documentation example

Completing the entry in the notes

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)
Completing the documentation
Completing the documentation

 

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