Standardized ECG Interpretation for Medical Charts
A properly structured ECG interpretation for a medical chart should follow a systematic format that includes rate, rhythm, axis, intervals, morphology, and a final impression with clinical correlation. 1
Essential Components of ECG Documentation
1. Basic Information
- Patient identifiers (name, ID number)
- Date and time of ECG recording
- Clinical indication for the ECG
- Comparison statement if prior ECGs are available
2. Systematic Interpretation Structure
Rate and Rhythm
- Heart rate (specify in beats per minute)
- Rhythm classification (e.g., normal sinus rhythm, atrial fibrillation)
- Presence of ectopic beats or escape rhythms if applicable
Intervals and Axis
- PR interval (normal: 120-200 ms)
- QRS duration (normal: <120 ms)
- QT/QTc interval (normal: QTc <450 ms for men, <460 ms for women)
- Axis determination (normal, left or right deviation)
Morphology Analysis
- Chamber enlargement findings if present
- Conduction abnormalities (e.g., bundle branch blocks, fascicular blocks)
- Repolarization abnormalities (ST-segment and T-wave changes)
- Q waves or pathological findings
Final Impression
- Summary statement of key findings
- Clinical correlation if applicable
- Comparison with previous ECGs using standardized comparison statements 1
Example Template
ECG INTERPRETATION:
Rate: [X] bpm
Rhythm: [e.g., Normal sinus rhythm]
Intervals: PR [X] ms, QRS [X] ms, QTc [X] ms
Axis: [Normal/Left/Right deviation]
Morphology: [Describe any abnormalities in P waves, QRS complexes, ST segments, T waves]
Impression: [Concise summary of findings]
Comparison to previous ECG (if available): [Use standardized comparison statement]Important Documentation Considerations
Primary vs. Secondary Statements
- Follow the hierarchical structure of primary statements (main diagnoses) followed by secondary statements (supporting findings) 1
- Primary statements should be clear and definitive
- Secondary statements must always accompany appropriate primary statements according to standardized pairing rules 1
Comparison with Previous ECGs
When comparing to previous ECGs, use standardized comparison statements such as:
- "No significant change" (when intervals remain normal or within 10% of previous values)
- "Significant change in rhythm" (when there's a new rhythm diagnosis)
- "New or worsened ischemia or infarction" (when applicable)
- "New conduction abnormality" (when AV or IV conduction diagnosis is added) 1
Special Populations
For athletes, note that certain findings considered abnormal in the general population may be normal variants, such as:
- Sinus bradycardia (≥30 bpm)
- Increased QRS voltage
- Early repolarization
- Incomplete RBBB 1
Common Pitfalls to Avoid
- Incomplete documentation: Failing to comment on all key components
- Overinterpretation: Attributing clinical significance to normal variants
- Underinterpretation: Missing subtle but significant findings
- Inconsistent terminology: Using non-standardized terms
- Lack of comparison: Not referencing previous ECGs when available
- Missing clinical correlation: Failing to relate findings to the patient's presentation
Clinical Implications
Remember that ECG interpretation directly impacts clinical decision-making. Accurate documentation is essential for:
- Diagnosing acute cardiac conditions
- Monitoring disease progression
- Guiding therapeutic interventions
- Providing medicolegal documentation
- Facilitating communication between healthcare providers
By following this standardized approach to ECG interpretation documentation, you ensure clear communication, appropriate clinical decision-making, and proper medical record keeping.