12 Lead Ekg Form PDF Details

The 12 Lead EKG is a critical tool in assessing the electrical activity of the heart, offering invaluable insights for diagnosing various heart conditions. Incorporating a comprehensive checklist, this form is designed to ensure meticulous adherence to procedure by healthcare professionals undergoing training. With spaces designated for preceptor initials and the date, the form verifies whether an employee has both observed and performed the essential steps involved in executing a 12 Lead EKG. Among these steps are the precise placement of electrodes on the patient's body, preparation of the skin to ensure accurate readings, and the proper utilization of the ECG machine. Each item on the checklist, from the placement of electrodes in specific intercostal spaces to the operational details of the ECG machine—like turning it on, entering patient information, and interpreting the results—is aimed at fostering proficiency in obtaining a reliable 12 Lead ECG. This form also emphasizes the importance of verbal communication by including a section for employees to verbalize the procedure's steps, ensuring a well-rounded understanding of both the theory and practice behind conducting a 12 Lead EKG. By signing at the bottom, the preceptor confirms the employee's competence, which is paramount in delivering optimal patient care.

QuestionAnswer
Form Name12 Lead Ekg Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesecg competency checklist, ekg competency checklist, 12 lead ekg checklist, ecgh online form com

Form Preview Example

12 Lead EKG Demonstration Checklist

*Preceptor please initial and date the appropriate column and sign your name at the bottom of the page.

Employee Name: ____________________________________ Date: _____________

12 Lead EKG

 

Observed/

Performed

 

 

Verbalized

 

1. Demonstrates proper lead placement for 12 Lead ECG

 

 

a.

V1 – 4th ICS; right sternal border

 

 

b.

V2 – 4th ICS; left sternal border

 

 

c.

V3 – Midway between location of V2 and V4

 

 

d.

V4 – 5th ICS; mid-clavicular line

 

 

e.

V5 - 4th ICS; to the right of V4 (anterior axillary line)

 

 

f.

V6 – 4th ICS; mid-axillary line

 

 

g.

Right arm, left arm, right leg, and left leg

 

 

2. Verbalizes steps to include in proper skin preparation for lead placement

 

 

a.

Clean area with alcohol swab

 

 

b.

Clip excess hair as necessary

 

 

3. Demonstrate ability to obtain a 12 lead ECG using the ECG machine.

 

 

a.

Apply electrodes as described above.

 

 

b.

Turn ECG machine on with ON/Standby button in lower Left corner of front panel

 

 

c.

Hit dark grey ID button on top of keyboard and enter MR# of pt

 

 

d.

Press F1 to enter the MR#

 

 

e.

Enter Pt name – Last, First – then hit F1 to enter

 

 

f.

Enter Age, then F1 to enter

 

 

g.

Enter Sex – M=male, F=female, then F1 to enter

 

 

h.

Press F1 to skip Operator prompt

 

 

i.

Enter 7N as Department, then F1 to enter

 

 

j.

Enter room number (4 digits), then F1 to enter

 

 

k.

Press F1 to skip prompts until you get to STAT ECG

 

 

l.

Press F2 to choose YES, then F1 to enter

 

 

m.

Then review screen and press AUTO (green button on left of panel) when legible ECG is obtained.

 

 

n.

Review ECG/Alert Physician of completed ECG

 

 

Preceptor ____________________________ Date ___________

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Step no. 1 for completing ecg checklist

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