ELECTROCARDIOGRAPHY

ELECTROCARDIOGRAPHY

STUDENT NAME _________________________

SECTION I:   UNASSISTED PERFORMANCE OF ECG

EVALUATOR: Each student must successfully perform and document a minimum of  TWO (2) unassisted Electrocardiogram procedures (on different patients) under the direct supervision of the clinician. The date of each procedure and the initials of clinician are to be recorded below.

 UNASSISTED SKILL PERFORMANCE DATE & INITIAL   #1               #2

SECTION II:   COMPETENCY OF ECG

EVALUATOR: A final competency may be performed after completion of two unassisted ECG’s performed under the supervision of a clinician. Competency is to be recorded on the section below.

COMPETENCY SCORE:             S = Satisfactory     U = Unsatisfactory     N/A= Not applicable    

ANY unsatisfactory column R indicates that the skill is not mastered and the student must repeate the competency.  

COMPETENCY ELECTROCARDIOGRAPHY

 

S

 

U

N/A

Identify the location of the code or emergency cart. (if applicable)

 

 

 

Assemble all necessary materials and ECG cart prior to beginning.

 

 

 

Check ECG for adequate paper supply.

 

 

 

Identify the patient by matching order with verbal information. (DOB and/or SS#)

 

 

 

Greet the  patient in a friendly manner and explain the purpose of the ECG.

 

 

 

Explain the procedure to the patient.

 

 

 

Assist the patient to gown for the ECG if applicable.

 

 

 

Assist the patient into the supine position.

 

 

 

Wash hands. Apply gloves (if indicated)

 

 

 

Maintain privacy throughout the examination.

 

 

 

Prepare skin for electrodes.

 

 

 

Apply electrodes with correct limb lead placement.

 

 

 

Apply electrodes with correct chest lead placement.

 

 

 

Use appropriate bony landmarks for lead placement.

 

 

 

Enter specific patient information into ECG machine.

 

 

 

Attach correct lead wire to appropriate electrode.

 

 

 


 

 

 

S

U

 

N/A

Verify lead placement prior to ECG recording.

 

 

 

Press “record” on the ECG machine.

 

 

 

Attempt to eliminate artifacts “noise”.

 

 

 

Remove lead wires from electrodes.

 

 

 

Remove electrodes from patient.

 

 

 

 

 

 

 

 

 

 

 

Discard electrodes and contaminated materials appropriately.

 

 

 

Wash your hands.

 

 

 

Maintain confidentiality throughout procedure.

 

 

 

Assist the patient from supine position.

 

 

 

Assist the patient to dress if applicable.

 

 

 

Assure patient safety throughout the procedure.

 

 

 

Escort patient to waiting room, exam room, front desk, per department protocol.

 

 

 

Leave  patient courteously and respectifully.

 

 

 

POST PROCEDURE:

 

 

 

Label ECG with patient name, date, time, ID number etc. if applilcable.

 

 

 

Document any special information on ECG.

 

 

 

Sign/initial completion of the procedure as per office protocol. (ie patient chart)

 

 

 

Clean up area and supplies, discard waste appropriately.

 

 

 

Follow office protocol for billing after examination. (indicate on statement/chart)

 

 

 

Other:

 

 

 

 COMMENTS_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 After observing _________________________ perform an electrocardiogram, I feel that he/she is competent to perform this task with minimal assistance.

 ________________________________________                            _________________

                     EVALUATOR SIGNATURE                                                                     DATE                 _______________________________________                            _________________

                     STUDENT SIGNATURE                                                                         DATE                

 FINAL COMPETENCY GRADE WILL BE ASSIGNED BY THE CLINICAL COORDINATOR                 PASS _______    REPEAT  ______

_____________________________________________                         _________________

           CLINICAL COORDINATOR SIGNATURE                                                              Date

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