Date of Device Check
/
Month
/
Day
Year
Date
Patient Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
Patient Device History: Enrolled in Monitoring?
Yes
No
Baseline Rhythm
Underlying Rhythm
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Baseline Device Information
Device Information
Post Op
Follow up:
Device Company
ABT
BSC
BTK
MDT
Device Type
PPM
ICD
CRT
ILR
Model Number / Name
Serial Number
Implant Date
/
Month
/
Day
Year
Date
Battery Voltage / Longevity
Pacing Mode
Pacing Rate (LRL/URL)
Ap (%)
Vp (%)
ICD Charge Time
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Lead Information
Atrial Lead Information
P wave
mV
Atrial Fibrillation?
Yes
No
Atrial Impedance
A Threshold
in Volts
Pulse Width (ms)
RV Lead Information
RV R wave
RV Impedance
Shock Impedance
RV Threshold
Pulse Width
ms
LV Lead Information
LV R wave
LV Impedance
LV Threshold
LV Pulse Width
ms
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Arrhythmia Information
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Episodes / Therapy
Changes Made
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Arrhythmia Information
Any further information about arhythmias detected? If so, place information here.
SVT: Number
Number of beats
SVT Length
Time
SVT Atrial Rate
SVT V Rate
AT/AF: Number
Number of beats
AF Burden
Percentage
Afib Ventricular Rate
AFib Atrial Rate
VT/VF: Number
VT/VF Length
VT/VF Atrial Rate
ATP? If so, how many rounds?
Shock?
VT Monitor
VT Length
Time
V Rate During VT
A Rate (during VT)
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Billing
Interrogation
Please Select
Pacemaker 93288
ICD 93289
ILR 93291
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Programming
Please Select
Pacemaker
Defibrillator
ILR
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Programming
Please Select
PPM Programming Single Lead 93279
PPM Programming Dual Lead 93280
PPM Programming Multiple Lead 93281
ICD Programming Single Lead 93282
ICD Programming Dual Lead 93283
ICD Programming Multiple Lead 93284
ILR Programming 93285
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Date Completed
/
Month
/
Day
Year
Date
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