PLACE LABEL HERE
cardiology STRESS ECHOCARDIOGRAM
WORKSHEET Cardiology Location: q gmc-L q GMC-D
Date: ______q Treadmill q DOBUTamine
Ordering Physician: ______Referring/PCP: ______
q Inpatient Room #______q Outpatient Phone #______
Allergies: ______
Allergy bracelet in place or noted on ID band: q Yes Weight: Stated weight _____ lbs, actual weight ______ kg
Indication for Stress Echocardiogram: ______
Current Medications: See Home Medicines List (Medication Reconciliation) or Inpatient Chart
History Assessment Hand- off Process
q CP, MI, HF, HTN, PCI, CABG q Alert & Oriented q Report received from ______@______am/pm
q Diabetic q Resp Reg & Non-labored
q Asthma, COPD q Oxygen in use q Report given to ______@______am/pm
q Smokes______q Skin warm, dry & pink
q Chest Pain ____ (0-10 scale) q IV patent OR ____Gauge started by ______Site ______
Arrival BP______HR______(DOBUTamine only)
PMHR______100%______85%
HR / BP / PainSupine
Standing
____Min
____Min
____Min
____Min
____Min Post
TIME / SYMPTOMS/COMMENTS/MEDICATIONS
Post Procedure Chest Pain ______(0-10 scale) Test performed by ______
q DOBUTamine _____mg was infused intravenously up to a rate of ______mcg/kg/min according to procedure.
q Atropine_____mg given due to a sub maximal heart rate response.
Contrast: q No qYes q Definity (perflutren) Dosage ______ml direct IV bolus Lot #: ______
Side Effects: q No q Yes: ______
Resting ECG q Sinus Rhythm q WNL q Sinus Bradycardia q Sinus Tachycardia q A-fib q RBBB q LBBB
q Non specific ST-T wave changes q Repolarization Abnormalities Resting HR______Resting BP______
Termination q Target HR achieved q Dyspnea q HTN q Fatigue q V-tach q Hypotension q Chest pain
Stress ECG q Sinus Rhythm q Sinus Bradycardia q Sinus Tachycardia q A-fib q RBBB q LBBB
q Non specific ST-T wave changes q Repolarization Abnormalities
Peak HR ______Peak BP______
Arrhythmias q No arrhythmias noted Comments: ______
Symptoms q Patient did not experience chest pain Comments: ______
Summary q No ECG changes suggestive of ischemia Comments: ______
______
Name of Technician Name of Sonographer
______
Date/Time RN Signature Date/Time APP/Cardiologist Performing Procedure PID #
*1-20015* FORM 1-20015 REV. 10/2016