Documentation and handover
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Documentation of ECG Findings: Importance and Guidelines
Importance of Proper Documentation
Identifiability: Ensure that the printed 12-lead ECG includes the patient's name and date of birth at the top to prevent loss and facilitate tracking of progress in heart conditions over time.
Documentation Process
Time and Type: Record the time of the ECG and specify whether it was a 3-lead or 12-lead ECG.
Difficulties and Artefacts: Note any challenges encountered during the ECG procedure, such as difficulties obtaining clear readings or the presence of artefacts.
Abnormalities: Document any abnormal findings observed during the ECG, including the specific abnormality and its characteristics.
Handover and Communication
Verbally and Written: Verbally communicate the documented findings during handover to ensure clear understanding. Provide a written record for future reference.
Continuity of Care: The next healthcare professional should be able to access the documented information to assess changes in the patient's condition.
Linking Symptoms and ECG Findings
Documented Symptoms: Describe the symptoms the patient experienced at the time of the ECG, such as palpitations, chest pain, or dizziness.
Changes in Symptoms and ECG: Indicate if symptoms have improved or worsened since the ECG. Note any corresponding changes in the ECG readings.
Summary
Ensure a comprehensive documentation process by including patient information, ECG details, encountered difficulties, observed abnormalities, and the link between symptoms and ECG findings. Effective communication during handover is crucial for continuity of care.
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