IAC Cardiac Electrophysiology

Procedure Checklist

Submit the following required documentation for each submitted patient procedure.Please do not anonymize any of the documentation.

If any of the following documentation is not available as a separate document(s), it/they must be a part of and clearly identified in one or more documents provided with this application.

Instructions:This form must be completed for each case study/procedure:

  1. Procedure/Case information:

Case # (Your case log number or Patient ID):

Date of procedure:

Operator:

Indication:

Type of procedure:

  1. Pre-procedure documentation:

Complete patient history and physical exam documentation that includes, but not limited to:

  • the appropriate clinical indication for the procedure:
  • medication and allergies
  • patient and family histories

Pre-procedure cardiovascular assessment documentation that includes, but not limited to:

  • severity and associated symptoms:
  • heart rate and rhythm: BPM
  • comorbidities:

Pre-procedural 12 Lead Electrocardiogram

Final report or report of findings for all relevant preliminary diagnostic and invasive testing performed

If applicable, documentation of all device and lead hardware present, including those in use and previously abandoned

  1. Procedure documentation:

Procedure specific informed consent

Complete procedure summary documentation to include, but not limited to:

Documentation of correct patient and procedure

Nurse monitoring report during the procedure

Anesthesia monitoring report during the procedure

Physician final procedural report

If fluoroscopy is used please complete one or more of the following:

  • Fluoroscopy Time:
  • Cumulative dose:
  • Dose Area Product (DAP):

Complications, if any; or absence of complications

  1. Post procedure documentation:

Documentation of post-procedural rhythm

Post-procedure cardiovascular assessment within 24 hours or prior to discharge documentation that includes, but not limited to:

  • severity and associated symptoms:
  • heart rate and rhythm: BPM

Patient status post procedure:

Discharge instructions

  1. Was the following documentation submitted for this study?

Clinical diagnosis leading to the cardiac electrophysiology procedure

Patient history and physical documentation

Cardiac Electrophysiology procedure report

Nurse monitoring report during the procedure

Anesthesia monitoring report during the procedure

Cardiovascular assessment documentation pre-procedure

Cardiovascular assessment documentation post-procedure

Discharge Instructions

Most recent reports from prior testing germane to the cardiac electrophysiology procedure being

performed

IAC Cardiac Electrophysiology Procedure Checklist1

Updated 9/21/2017