In addition to knowing how to record and interpret an ECG, it’s also important to understand how to appropriately document an ECG in a patient’s notes. This guide provides a structured approach to documenting ECGs in a patient’s notes, with included examples.
Before we discuss how to document the ECG itself, 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 here 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).
For every new sheet of paper (including the ECG itself) your first task should always be documenting at least three key identifiers for a patient:
- Full name
- Date of birth
- Unique patient identifier
- Patient’s home address
If a patient label containing at least 3 identifiers is available then this can be used instead of writing out the information yourself.
You should indicate the patient’s location on the continuation sheet:
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.
1. Add the date and time (in 24hr format) of your entry
2. Write your name and role as an underlined heading
3. Make your entry in the notes below this heading (see the next section for details)
Documenting the ECG results in the notes
1. Document the time and date that the ECG was performed (as this may be significantly different than 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 here):
- 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
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. Medical student/F2/Cardiology registrar)
- Your signature
- Your professional registration number (e.g. GMC number)
- Your contact number (e.g. phone/bleep)