ELECTROCARDIOGRAM PROCEDURE

Effective Date: 
Thu, 08/04/2011
Reviewed: 
Tue, 08/23/2011
Revised: 
Tue, 09/12/2017
Policy: 

SUBJECT: Electrocardiogram Procedure

PERSONNEL: RN, LVN, MA

EQUIPMENT: Midmark 12-lead IQ EKG

Procedure: 

MACHINE PREPARATION:
Connect the portable unit to an exam room computer’s USB port. Snap lead attachment into base of portable unit. Open the correct patient’s visit note and confirm nursing order, if needed.

PATIENT PREPARATION:
Assure patient there is no danger or pain involved. Have the patient remove clothing above the waist and don in a cloth gown opening to the front. Make the patient comfortable lying down on the exam table. Expose the arms and legs. If necessary shave the electrode areas before cleaning the exposed skin with alcohol for proper electrode adhesion.

Limb Sensor Application
Place the sensors on a smooth fleshy area of the upper inner arms and lower inner legs. Attach the limb leads.
Chest Sensor Application
Place the 6 Chest sensors on the patient’s chest as follows:
V1 Fourth intercostal space at right border of the sternum
V2 Fourth intercostal space at left border of the sternum
V3 Midway between position V2 and position V4
V4 At the mid-clavicular line in the fifth intercostal space
V5 At the anterior axillary line on the same horizontal level as V4
V6 At the mid-axillary line on the same horizontal level as V4 and V5
Attach the chest leads.

RECORDING THE EKG and RHYTHM STRIP (RR):

Confirm that standard vital signs obtained and entered into chart note, included current height and weight. If not, perform vitals before starting EKG.

Confirm chart note is closed before starting EKG.

12-LEAD and RHYTHM STRIP Capture

From the patient’s chart:

  • Select EKG/PFT from list on left side of screen
  • Select Acquire > ECG at top of screen and enter ordering clinician’s name (see below for Psychiatry process)
  • The Midmark module will open automatically
  • When you have clean tracing, click Analyze to capture the 12-lead
    • If tracing shows interference, confirm patient is still, no metal in pockets, leads placed correctly, etc.
  • Click RR to capture rhythm strip; it is set to record for 30 seconds
    • After recording 30 seconds of rhythm strip, the Review option becomes available; click it to save the results
  • Confirm that both 12-lead and rhythm strip documents have saved before notifying clinician

When done as part of a clinician visit, consult with ordering provider or other appropriate clinical staff before disconnecting leads and allowing patient to dress.

If done as a nursing visit or through Psychiatry, see below.

Charge captured automatically when EKG is documented as performed through PnC>Open Chart>Nursing>Procedure Sheet.

AFTER THE RECORDING:

We do not routinely submit all EKGs for review by an outside specialist. The need for outside review is at the discretion of the ordering clinician. Requests for interpretation by a specialist are documented on the tracing by the ordering clinician, then tracked by the Health Information Management (HIM) Department.

Documentation for 12-lead and RR consists of four steps:

  • Review
  • Enter Comments-“Keep”, “Send out”, relevant clinical information, initials
  • Sign
  • Acknowledge

EKGs ordered within a clinician visit, whether normal or abnormal, must be reviewed by the ordering clinician, who will determine patient disposition and whether the 12-lead and RR are “Keep” or “Send out”.  

The ordering provider or their designee clicks Review, enters “Keep” or “Send out” in the Comment section of each, initials each entry, then Exits and Saves the changes.

12-Lead: Auto-generated interpretation appears on document. To record comments, including “Keep” or “Send out”, click “Review”, click “Details”, then “Edit Comment” to open Comment section. Type comments, including relevant clinical information for the outside specialist, click “OK”, click “OK” again, and “Exit”, then “Yes” to save changes.

RR: No auto-generated interpretation appears on document; Comment section directly opens during Review process.

If “Keep”:

  • Enter Comments, initial the entry, Exit and Save changes
  • Sign
  • Acknowledge

If “Send out”:

  • The ordering provider or their designee clicks Review, enters “Send out” in the Comment section of each, adds any relevant clinical information, initials each entry, Exits and Saves the changes.  DO NOT SIGN OR ACKNOWLEDGE AT THIS STEP.
  • Health Information Management (HIM) runs daily report of unacknowledged EKGs and sends secure message to outside specialist to request reading, using the designated “EKG Clinician” provider in the EMR.
  • Outside specialist remotely accesses EMR at regular intervals and reads any pending EKGs and RRs.
  • Specialist adds interpretation in Comments and Signs electronic documents.
  • Health Information Management (HIM) notifies ordering clinician when 12-lead and RR has been reviewed and signed by the outside specialist, making it ready for acknowledgement.
  • Ordering clinician Acknowledges interpreted 12-lead and RR.

If an urgent interpretation is indicated, the Medical Director will communicate directly with the outside specialist.

Nurse-performed EKG for Routine Testing: As part of a physical prior to be being seen by a clinician (i.e. diving physical).

  • Nurse performs 12-lead and RR, designating the Medical Director as the ordering clinician.
  • Normal sinus rhythm: Patient is discharged. The Medical Director will review the tracings and enter “Keep” or “Send out” comments.
  • Abnormal Results: If the automated reading reports anything other than “normal sinus    rhythm” or if the nurse has any clinical concerns, the EKG will be reviewed by the DOC or Medical Director prior to the patient leaving.
  • Charge captured automatically when EKG is documented as performed through PnC>Open Chart>Nursing>Procedure Sheet.

EKGs ordered by Psychiatry: All EKGs ordered by Psychiatry are considered "Diagnostic".

  • The nursing order is placed by the psychiatrist.
  • The nurse/MA enters the Medical Director, not the psychiatrist, as the ordering clinician in the patient’s chart.
  • Normal sinus rhythm: results are reviewed by the Medical Director, who will determine “Keep” or “Send out”.
  • Abnormal results: If the automated reading reports anything other than “normal sinus    rhythm” or if the nurse/MA has any clinical concerns, the EKG will be reviewed by the DOC or Medical Director prior to the patient leaving.
  • Charge captured automatically when EKG is documented as performed through PnC>Open Chart>Nursing>Procedure Sheet.

HEALTH INFORMATION MANAGEMENT PROCESS:

  • HIM staff runs unacknowledged EKG report daily to determine the following:
    • If “Keep” but unacknowledged, HIM staff will alert the ordering provider regarding signing and acknowledging EKG.
    • If “Send out”, HIM staff monitors unacknowledged EKG and alerts ordering provider when outside specialist has entered documentation and signed the 12-lead and RR. HIM staff will alert the ordering provider regarding acknowledging EKG.