12-lead ECG Abnormalities Form

Administrative data
Description

Administrative data

Subject Identifier
Description

Subject Identifier

Data type

integer

List of Abnormalities
Description

List of Abnormalities

Date of ECG
Description

Date of ECG

Data type

date

Time of ECG
Description

Time of ECG

Data type

time

Record clinically significant abnormalities below. Mark all that apply:
Description

Record clinically significant abnormalities below. Mark all that apply:

A. Rhythm
Description

A. Rhythm

Data type

text

Comment
Description

Comment

Data type

text

B. P-Wave and QRS Morphology
Description

B. P-Wave and QRS Morphology

Data type

text

Comment
Description

Comment

Data type

text

C. Conduction
Description

C. Conduction

Data type

text

Comment
Description

Comment

Data type

text

D. Myocardial Infraction
Description

D. Myocardial Infraction

Data type

text

Comment
Description

Comment

Data type

text

E. Depolarisation/Repolarisation (QRS-T)
Description

E. Depolarisation/Repolarisation (QRS-T)

Data type

text

Comment
Description

Comment

Data type

text

Other abnormalities
Description

Other abnormalities

Data type

text

Comment
Description

Comment

Data type

text

Similar models

12-lead ECG Abnormalities Form

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Administrative data
Subject Identifier
Item
Subject Identifier
integer
Item Group
List of Abnormalities
Date of ECG
Item
Date of ECG
date
Time of ECG
Item
Time of ECG
time
Item Group
Record clinically significant abnormalities below. Mark all that apply:
Item
A. Rhythm
text
Code List
A. Rhythm
CL Item
[A1] Sinus bradycardia (1)
CL Item
[A21] Sinus bradycardia (heart rate 40-50 bpm) (2)
CL Item
[A22] Sinus bradycardia (heart rate 30-39 bpm) (3)
CL Item
[A23] Sinus bradycardia (heart rate <30 bpm) (4)
CL Item
[A3] Sinus pause (5)
CL Item
[A2] Sinus tachycardia (heart rate >100 bpm) (6)
CL Item
[A4] Ectopic supraventricular beats (7)
CL Item
[A20] Ectopic supraventricular rhythm (8)
CL Item
[A17] Wandering atrial pacemaker (9)
CL Item
[A26] Multifocal atrial tachycardia (Wandering atrial pacemaker with heart rate >100 bpm) (10)
CL Item
[A6] Supraventricular tachycardia (heart rate >100 bpm) (11)
CL Item
[A7] Atrial flutter (12)
CL Item
[A8] Atrial fibrillation (13)
CL Item
[A5] Junctional rhythm (heart rate <=100 bpm) (14)
CL Item
[A25] Junctional rhythm (15)
CL Item
[A24] Junctional tachycardia (heart rate > 100 bpm) (16)
CL Item
[A9] Ectopic ventricular beats (17)
CL Item
[A12] Ventricular couplets (18)
CL Item
[A13] Bigeminy (19)
CL Item
[A28] Trigeminy (20)
CL Item
[A14] Electrical alternans (21)
CL Item
[A29] R on T phenomenon (22)
CL Item
[A18] Ventricular fibrillation (23)
CL Item
[A19] Idioventricular rhythm (heart rate < 100 bpm) (24)
CL Item
[A10] Sustained ventricular tachycardia (25)
CL Item
[A11] Non-sustained ventricular tachycardia (26)
CL Item
[A32] Wide QRS Tachycardia (diagnosis unknown) (27)
CL Item
[A27] Ventricular tachycardia (28)
CL Item
[A30] Monomorphic ventricular tachycardia (29)
CL Item
[A15] Torsades de Pointes (Polymosphic ventricular tachycardia with prolonged QT) (30)
CL Item
[A31] Polymorphic (sustained and non-sustained) ventricular tachycardia (31)
CL Item
[A16] Artificial pacemaker (32)
CL Item
[A99] Other abnormal rhythm (33)
Comment
Item
Comment
text
Item
B. P-Wave and QRS Morphology
text
Code List
B. P-Wave and QRS Morphology
CL Item
[B1] Left atrial abnormality (P mitrale) (1)
CL Item
[B2] Rightatrial abnormality (P pulmonale) (2)
CL Item
[B3] Right ventricular hypertrophy (3)
CL Item
[B5] Intraatrial conduction delay (4)
CL Item
[B14] Increased voltage consistent with left ventricular hypertrophy (5)
CL Item
[B99] Other morphology (6)
Comment
Item
Comment
text
Item
C. Conduction
text
Code List
C. Conduction
CL Item
[C1] First degree AV block (PR interval > 200 msec) (1)
CL Item
[C20] Short PR interval (2)
CL Item
[C2] Second degree AV block (Mobitz type 1) (3)
CL Item
[C3] Second degree AV block (Mobitz type 2) (4)
CL Item
[C16] 2:1 AV block (5)
CL Item
[C4] Third degree AV block (6)
CL Item
[C5] Left axis deviation (QRS axis more negative than -30°) (7)
CL Item
[C6] Right axis deviation (QRS axis more positive than +110°) (8)
CL Item
[C7] Incomplete right bundle branch block (9)
CL Item
[C13] Incomplete left bundle branch block (10)
CL Item
[C8] Right bundle branch block (11)
CL Item
[C14] Left anterior hemiblock (synonymous to left anterior fascicular block) (12)
CL Item
[C15] Left posterior hemiblock (synonymous to left posterior fascicular block) (13)
CL Item
[C9] Left bundle branch block (14)
CL Item
[C17] Bifascicular block (15)
CL Item
[C10] Non-specific intraventricular conduction delay (QRS >=120msec) (16)
CL Item
[C11] Accessory pathway (Wolff-Parkinson White, Lown-Ganong-Levine) (17)
CL Item
[C19] Prolonged QT interval (18)
CL Item
[C12] QT/QTc prolongation >=500 msec (19)
CL Item
[C18] AV dissociation (20)
CL Item
[C99] Other conduction  (21)
Comment
Item
Comment
text
Item
D. Myocardial Infraction
text
Code List
D. Myocardial Infraction
CL Item
[D1] Myocardial infraction, old (1)
CL Item
[D2] Myocardial infraction, anterior (2)
CL Item
[D3] Myocardial infraction, lateral (3)
CL Item
[D4] Myocardial infraction, posterior (4)
CL Item
[D5] Myocardial infraction, inferior (5)
CL Item
[D6] Myocardial infraction, septal (6)
CL Item
[D20] Myocardial infraction, Non-Q wave (7)
CL Item
[D98] Other myocardial infraction  (8)
Comment
Item
Comment
text
Item
E. Depolarisation/Repolarisation (QRS-T)
text
Code List
E. Depolarisation/Repolarisation (QRS-T)
CL Item
[D7] Non-specific ST-T changes (1)
CL Item
[D19] J point elevation (2)
CL Item
[D8] ST elevation (3)
CL Item
[D21] ST elevation-pericarditis (4)
CL Item
[D9] ST depression (5)
CL Item
[D10] U waves abnormal (6)
CL Item
[D11] T wave inversion (7)
CL Item
[D12] T wave peaked (8)
CL Item
[D15] T waves flat (9)
CL Item
[D16] T waves biphasic (10)
CL Item
[D18] Notched T-waves (11)
CL Item
[D13] Low QRS voltage (12)
CL Item
[D17] T-wave flattening/inversion (13)
CL Item
[D99] Other depolarisation/repolarisation  (14)
Comment
Item
Comment
text
Item
Other abnormalities
text
Code List
Other abnormalities
CL Item
[E99] Other abnormalities (1)
Comment
Item
Comment
text