Date of ECG

Time of ECG

Check YES for all that apply:

Sinus bradycardia

Sinus bradycardia (heart rate 40-50 bpm)

Sinus bradycardia (heart rate 30-39 bpm)

Sinus bradycardia (heart rate <30 bpm)

Sinus pause

Sinus tachycardia (heart rate >100 bpm)

Ectopic supraventricular beats

Ectopic supraventricular rhythm

Wandering atrial pacemaker

Multifocal atrial tachycardia (Wandering atrial pacemaker with heart rate >100 bpm)

Supraventricular tachycardia (heart rate >100 bpm)

Atrial flutter

Atrial fibrillation

Junctional rhythm (heart rate <=100 bpm)

Junctional rhythm

Junctional tachycardia (heart rate > 100 bpm)

Ectopic ventricular beats

Ventricular couplets

Bigeminy

Trigeminy

Electrical alternans

R on T phenomenon

Ventricular fibrillation

Idioventricular rhythm (heart rate < 100 bpm)

Sustained ventricular tachycardia

Non-sustained ventricular tachycardia

Wide QRS Tachycardia (diagnosis unknown)

Ventricular tachycardia

Monomorphic ventricular tachycardia

Torsades de Pointes (Polymosphic ventricular tachycardia with prolonged QT)

Polymorphic (sustained and non-sustained) ventricular tachycardia

Artificial pacemaker

Other abnormal rhythm

Left atrial abnormality (P mitrale)

Rightatrial abnormality (P pulmonale)

Right ventricular hypertrophy

Intraatrial conduction delay

Increased voltage consistent with left ventricular hypertrophy

Other morphology

First degree AV block (PR interval > 200 msec)

Short PR interval

Second degree AV block (Mobitz type 1)

Second degree AV block (Mobitz type 2)

Second degree AV block (Mobitz type 2)

2:1 AV block

Third degree AV block

Left axis deviation (QRS axis more negative than -30°)

Right axis deviation (QRS axis more positive than +110°)

Incomplete right bundle branch block

Incomplete left bundle branch block

Right bundle branch block

Left anterior hemiblock (synonymous to left anterior fascicular block)

Left posterior hemiblock (synonymous to left posterior fascicular block)

Left bundle branch block

Bifascicular block

Non-specific intraventricular conduction delay (QRS >=120msec)

Accessory pathway (Wolff-Parkinson White, Lown-Ganong-Levine)

Prolonged QT interval

QT/QTc prolongation >=500 msec

AV dissociation

Other conduction

Myocardial infraction, old

Myocardial infraction, anterior

Myocardial infraction, lateral

Myocardial infraction, posterior

Myocardial infraction, inferior

Myocardial infraction, septal

Myocardial infraction, Non-Q wave

Other myocardial infraction

Non-specific ST-T changes

J point elevation

ST elevation

ST elevation-pericarditis

ST depression

U waves abnormal

T wave inversion

T wave peaked

T waves flat

T waves biphasic

Notched T-waves

Low QRS voltage

T-wave flattening/inversion

Other depolarisation/repolarisation

Other Abnormalities, enter comment