12-Lead ECG Acquisition/Interpretation Note (EMS)

Date/Time: [Date and time of ECG acquisition]

ECG #: [ECG #1 / ECG #2 / ECG #3]

First Medical Contact Time: [Time] (If unavailable, state "Not captured: [reason]")

Location: [scene / ambulance / other]

Device: [Monitor make/model and unit ID]

Acquired by: [Clinician name and credential]

Interpreted by: [Clinician name and credential / Transmission only - no EMS interpretation per protocol / Remote interpretation by [role]]

Clinical Context

[HPI-style summary of indication and context] (2–4 sentences. Include: chief complaint or trigger symptom; symptom onset time with qualifier such as "approximate" or "unknown" if uncertain; whether symptoms were present at the moment of acquisition; pertinent factors affecting ECG quality or interpretation such as shivering, diaphoresis, agitation, movement, implanted device, or positioning constraints. Do not infer details not stated.)

Vitals near ECG time: HR: [heart rate] bpm; BP: [blood pressure] mmHg; SpO2: [oxygen saturation]% on [room air / supplemental oxygen]; Pain score: [0–10 / not assessed]

Pertinent cardiac history: [Relevant history such as CAD, prior MI, PCI/CABG, pacemaker, known BBB / None known / Unknown] (Include only if known and relevant)

Acquisition

ECG Type: [12-lead standard / right-sided (V3R–V4R) / posterior (V7–V9) / 15-lead / 18-lead]

Patient Position: [supine / semi-Fowler / sitting / other]

Limb Lead Placement: [standard distal limb placement / torso or proximal placement]

Skin Prep: [cleaned and dried / shaved / barriers present: [describe]]

Delay reason: [Reason for delay] (Include only if acquisition exceeded 10-minute protocol target)

Quality Assessment

(If quality is adequate, use: "Quality: Adequate for interpretation; no lead placement concerns." If limited or issues present, use the detailed format below instead.)

Interpretability: [Interpretable / Limited / Uninterpretable]

Artifact/Issues: [motion artifact / tremor or shivering / poor electrode contact / electrical interference / baseline wander / suspected lead reversal or misplacement / modified electrode placement due to [reason]]

Corrective Actions: [skin re-prepped / electrodes replaced / leads repositioned / repeat ECG obtained]

(If quality is limited, avoid definitive ischemia statements unless the limitation does not affect the relevant leads.)

Interpretation

Method: [Computer interpretation / Manual interpretation by EMS clinician / Transmission only (no EMS interpretation per protocol) / Transmitted for remote interpretation by [role]]

Computer interpretation: [Machine statement verbatim] (Include exact machine language; do not paraphrase)

(If manual interpretation is permitted and performed, document findings below.)

• Rhythm and Rate: [Rhythm description] at [rate] bpm
• Conduction: [normal / AV block [degree] / LBBB / RBBB / paced rhythm]
• ST/T Findings: [Lead-based description with magnitude if measured; note presence or absence of reciprocal changes; if none: "No ST elevation or depression"]

STEMI Criteria: [Meets STEMI activation criteria per protocol / Does not meet activation criteria / Findings borderline or uncertain] (Use protocol language; do not diagnose MI)

Comparison: Compared to ECG #[number] at [time]: [change or no significant change] (Include only if prior ECG obtained this encounter)

Serial ECG Entry

(Include this section only if repeat ECG was obtained; otherwise omit entirely.)

• ECG #[X] at [time]: Indication: [persistent symptoms / clinical deterioration / nondiagnostic initial ECG / protocol requirement]. Quality: [interpretable / limited]. Key finding or change: [description]. Actions triggered: [repeat transmission / STEMI alert / therapy adjusted / none].

(If repeat ECG was indicated but not performed, document reason: [transport time insufficient / patient refused / unsafe environment / other].)

Transmission and Notifications

• Transmitted: [yes / no]; Time: [time]; Destination: [receiving ED / PCI center / telemetry hub]; Receipt confirmed: [yes / no]
• STEMI Alert: [activated / not activated]; Time: [time]; Notified: [recipient and method]
• Medical Direction: [consulted / not consulted]; [Brief summary of direction received]
• Transport Decision: Destination: [PCI-capable center / nearest ED]; Rationale: [ECG-influenced per protocol / other rationale]

(If no transmission capability exists, document: "No transmission capability available: [reason].")

Handoff

Printed copy provided to receiving team: [yes / no]

Electronic copy attached to ePCR: [yes / no]

Issues: [None / describe issue and resolution] (Include only if attachment or printing problems occurred)

Attestation

[Clinician name, credential, agency/unit]

[Remote interpreter identity or service] (Include only if remote interpretation occurred)