12 Lead Ekg Form PDF Details

Electrocardiography, also known as an EKG or ECG, is a test that records the electrical activity of the heart. This test is used to diagnose heart conditions and track the progress of treatment. The 12 lead EKG is a more comprehensive version of the traditional EKG, and can provide doctors with more information about heart health. In this blog post, we will take a closer look at the 12 lead EKG form and what it can tell us about heart health. Stay tuned!

Form Name12 Lead Ekg Form
Form Length1 pages
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








1. Demonstrates proper lead placement for 12 Lead ECG




V1 – 4th ICS; right sternal border




V2 – 4th ICS; left sternal border




V3 – Midway between location of V2 and V4




V4 – 5th ICS; mid-clavicular line




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




V6 – 4th ICS; mid-axillary line




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



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




Clean area with alcohol swab




Clip excess hair as necessary



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




Apply electrodes as described above.




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




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




Press F1 to enter the MR#




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




Enter Age, then F1 to enter




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




Press F1 to skip Operator prompt




Enter 7N as Department, then F1 to enter




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




Press F1 to skip prompts until you get to STAT ECG




Press F2 to choose YES, then F1 to enter




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




Review ECG/Alert Physician of completed ECG



Preceptor ____________________________ Date ___________

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Step no. 1 for completing ecg checklist

2. Just after completing this part, head on to the subsequent step and enter all required particulars in all these blanks - a Apply electrodes as described, and Preceptor Date .

Filling in segment 2 of ecg checklist

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