PE Response Data Collection Form

PE Response Team Data Collection Form

The PE Data Collection Form is designed to capture essential clinical, procedural, and outcome data for patients undergoing interventions for pulmonary embolism. Please follow the instructions below to ensure accurate and complete data entry.
Who to Include
Submit cases only if:
- A PERT activation occurred
- The patient has acute (or suspected) PE
- The patient is intermediate- or high-risk
- The patient is 18 or older
- All treatment types are included (e.g., anticoagulation, thrombolytics, thrombectomy)
  
  Who NOT to Include
  Do not submit:
- Cases without PERT activation
- Chronic (non-acute) PE
- Patients under 18
- Cases with missing key information
  
  Important
  Enter all eligible PERT cases—do not limit submissions to specific treatments.
Organization information
Name of person completing this form

First NameLast Name
Organization/Site
Email
example@example.com
Patient Information
Age
FemaleMaleNon-binaryDid not disclose
Date of Procedure:

MonthDayYear
Date

Rows	Yes	No	Score/Event, if applicable,
RV Strain
Troponin Elevated (HS Troponin >50)
Syncope Event
Hypotension (SBP < 90)
Hypotension (low BP 90-100)
Need for Pressors
O2 Sat <90%
Tachycardia (HR >110)
S-PESI Score
PESI Score
Lactate Score

PE Response Team Data Collection Form