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    Resting ECG Report Form

    Uploaded by

    Karthik S
    This document is a UK CAA resting ECG report form. It lists various findings that may be present on an ECG like abnormal heart rates, rhythms, conduction issues, ST segments, T waves, and axes. It also includes spaces for the applicant's name and date of the ECG recording. The cardiologist can indicate if additional information is provided, their assessment of the findings, and any recommendations like a cardiology review or further tests. They must sign the report with their name, GMC number, and date.

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    Resting ECG Report Form

    Uploaded by

    Karthik S
    278 views1 page
    This document is a UK CAA resting ECG report form. It lists various findings that may be present on an ECG like abnormal heart rates, rhythms, conduction issues, ST segments, T waves, and axes. It also includes spaces for the applicant's name and date of the ECG recording. The cardiologist can indicate if additional information is provided, their assessment of the findings, and any recommendations like a cardiology review or further tests. They must sign the report with their name, GMC number, and date.

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    This document is a UK CAA resting ECG report form. It lists various findings that may be present on an ECG like abnormal heart rates, rhythms, conduction issues, ST segments, T waves, and axes. It also includes spaces for the applicant's name and date of the ECG recording. The cardiologist can indicate if additional information is provided, their assessment of the findings, and any recommendations like a cardiology review or further tests. They must sign the report with their name, GMC number, and date.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    278 views1 page

    Resting ECG Report Form

    Uploaded by

    Karthik S
    This document is a UK CAA resting ECG report form. It lists various findings that may be present on an ECG like abnormal heart rates, rhythms, conduction issues, ST segments, T waves, and axes. It also includes spaces for the applicant's name and date of the ECG recording. The cardiologist can indicate if additional information is provided, their assessment of the findings, and any recommendations like a cardiology review or further tests. They must sign the report with their name, GMC number, and date.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    UK CAA RESTING ECG REPORT

    CAA Ref No ………………....… Applicant Name………………………..…...… ECG Recording Date……………....…… Date of ECG Report………....…

    ECG FINDINGS (Tick (√) if present) CARDIOLOGIST'S REPORT


    HEART RATE QRS Additional Information provided (Tick if provided)
    Tachycardia > 100bpm Q/QS Waves - Inferior Trace / Report of Previous ECG(s) See UK CAA Guidance material at
    Bradycardia < 50 (40 bpm) Q/QS Waves - Anterior-Septal Previous cardiology (report(s) www.caa.co.uk/medical
    Q/QS Waves - Anterior-Lateral
    Poor R Wave Progression
    HEART RHYTHM Max R Plus Max S > 50mm
    ASSESSMENT (Tick (√) as appropriate)
    Atrial ectopics Pre Excitation - Short PR, Normal QRS
    Ventricular ectopics Pre Excitation - Short PR, Delta Wave
    Findings Normal / Acceptable / No Change
    Ventricular ectopics with VT Pre Excitation - Normal PR, Delta Wave
    Junctional Long QTc (>470ms)
    Findings Require Investigation within 2/12
    Idioventricular
    Normal PR,Left Axis P Wave ST SEGMENT Unacceptable
    Atrial Fibrillation Depression - J Point Technically inadequate (e.g. Lead missing/switch, AC interference
    Atrial Flutter Depression - Planar Unacceptable New
    Depression - Downsloping finding of disqualifying condition - make applicant unfit
    Elevation
    CONDUCTION Leads - Anterior COMMENTS RECOMMENDATIONS
    see also ECG investigation triggers
    SA Block Leads - Inferior
    AV Block - 1st degree (PR>240ms) Leads - Diffuse Cardiology Review
    AV Block - 2nd Degree Type I Brugada Exercise ECG
    AV Block - 2nd Degree Type II ST Sag 24-hour ECG
    AV Block - Complete Echocardiogram
    RBBB - Complete T WAVE Other (Specify)……………….
    RBBB - Incomplete (RSR 1) Peaked
    LBBB - Complete Flat
    LBBB - Incomplete Notched REPORTING CARDIOLOGIST:
    Non-specific Intraventricular Inverted
    Conduction Delay Leads - Anterior - Septal
    Lead - Anterior - Lateral Signature
    Leads - Inferior
    AXIS Leads - Diffuse Name
    Leftward axis (>-30) Non-specific T-wave change
    Left Axis Deviation (>-45) GMC Number
    Right Axis Deviation U WAVES
    Indeterminate Prominent

    16/11/2014 ECG Form 108

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