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Resting ECG Report Form

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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Karthik S
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652 views1 page

Resting ECG Report Form

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.

Uploaded by

Karthik S
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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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