What is the procedure for performing an electrocardiogram (EKG)?

Performing an Electrocardiogram (EKG)

A standard 12-lead EKG must be performed according to established technical standards, with proper lead placement and patient positioning, and requires physician interpretation to be considered a valid medical record—computer interpretation alone is insufficient. 1

Technical Requirements for Valid EKG

Standard Recording Protocol

• The EKG must be a standard 12-lead recording with or without rhythm strips or additional special leads as clinically indicated 1
• In children and selected adults, additional leads beyond the standard 12 may be necessary for accurate assessment 1
• The recording should follow optimal electrocardiography guidelines as described in the American College of Cardiology 10th Bethesda Conference report 1

Critical Interpretation Requirements

• A physician qualified to interpret EKGs must review and interpret the tracing before it becomes part of the patient's medical record 1
• Computer-generated interpretations alone do not constitute a properly interpreted EKG and can be a source of erroneous information 1, 2
• The interpreting physician should follow a systematic, stepwise approach to ensure accurate analysis 2, 3

What Does NOT Constitute a Standard EKG

The following are not considered equivalent to a standard 12-lead EKG 1:

• Continuous ambulatory electrocardiography or telemetry monitoring
• Single monitor leads or rhythm strips alone
• Exercise testing tracings
• Transtelephonic recordings
• Signal-averaging techniques with late potentials
• Intracardiac electrograms

Important caveat: While these modalities provide valuable information, a 12-lead EKG is typically required for accurate interpretation or to provide complementary information 1

Quality Control Considerations

Avoiding Common Errors

• The responsible physician must recognize and account for patient-dependent errors, operator-dependent errors, and artifact 3
• Always compare current EKG tracings with previous tracings when available 3
• Follow a specific routine and methodical analysis to ensure accurate interpretation 3

Understanding EKG Limitations

• The EKG records electrical activity, so diagnoses of structural changes (myocardial infarction, hypertrophy) or pathophysiologic changes (electrolyte disturbances, drug effects) are made by inference and subject to error 1
• Each waveform component has its own sensitivity and specificity, which may be influenced differently by various pathologic and pathophysiologic factors 1

Training Requirements

• Physicians interpreting EKGs should have training consistent with the American College of Cardiology 17th Bethesda Conference report on cardiology training 1
• If uncertain about interpretation, tracings can be transmitted for consultation with a more experienced reader 3