Date of Device Check
/
Month
/
Day
Year
Date
Patient Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
Baseline Rhythm
Back
Next
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 (s)
Back
Next
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
mV
RV Impedance
Ohms
Shock Impedance
Ohms
RV Threshold
in Volts
Pulse Width
ms
LV Lead Information
LV R wave
mV
LV Impedance
Ohms
LV Threshold
in Volts
LV Pulse Width
ms
Back
Next
Arrhythmia Information
Please input any written details here
Episodes / Therapy
Narrative. Ventricular or supraventricular episodes details, any therapies given (ATP, shocks), any therapy changes recommended
Changes Made
If any alerts turned off?
Conclusion :
Please Select
Normal study
Otherwise normal study
Abnormal study
Upload Device Interrogation Here :
Browse Files
Drag and drop files here
Choose a file
PDF format preferred
Cancel
of
Back
Next
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 Length
Time
Afib Ventricular Rate
AFib Atrial Rate
VT/VF: Number
VT/VF Length
VT/VF Atrial Rate
ATP? If so, how many rounds?
Shock?
Please Select
No
Yes
VT Monitor
VT Length
Time
V Rate During VT
A Rate (during VT)
Back
Next
Billing
Diagnosis 1
Please Select
I63.9 Acute ischemic stroke
R00.2 Palpitations
R55 Syncope and collapse
I48.0. Atrial fibrillation
I48.3. Atrial flutter
R94.31. Abnormal EKG
I47.1. SVT
I 47.2. VT
R06.02. Shortness of breath
I46.2. Cardiac Arrest
I49.9. Cardiac Arrhythmia
I25.5. Ischemic cardiomyopathy
I42.1. Obstructive hypertrophic CM
I42.2. Other hypertrophic CM
I42.0. Dilated cardiomyopathy
I45.81 Long QT Syndrome
I44.3. Atrioventricular block
I49.5. Sick sinus syndrome
Z95.0 Presence of pacemaker
Z95.810. Presence of Defibrillator
Z95.818. Presence of ILR
Diagnosis 2
Please Select
I63.9 Acute ischemic stroke
R00.2 Palpitations
R55 Syncope and collapse
I48.0. Atrial fibrillation
I48.3. Atrial flutter
R94.31. Abnormal EKG
I47.1. SVT
I 47.2. VT
R06.02. Shortness of breath
I46.2. Cardiac Arrest
I49.9. Cardiac Arrhythmia
I25.5. Ischemic cardiomyopathy
I42.1. Obstructive hypertrophic CM
I42.2. Other hypertrophic CM
I42.0. Dilated cardiomyopathy
I45.81 Long QT Syndrome
I44.3. Atrioventricular block
I49.5. Sick sinus syndrome
Z95.0 Presence of pacemaker
Z95.810. Presence of Defibrillator
Z95.818. Presence of ILR
Diagnosis 3
Please Select
I63.9 Acute ischemic stroke
R00.2 Palpitations
R55 Syncope and collapse
I48.0. Atrial fibrillation
I48.3. Atrial flutter
R94.31. Abnormal EKG
I47.1. SVT
I 47.2. VT
R06.02. Shortness of breath
I46.2. Cardiac Arrest
I49.9. Cardiac Arrhythmia
I25.5. Ischemic cardiomyopathy
I42.1. Obstructive hypertrophic CM
I42.2. Other hypertrophic CM
I42.0. Dilated cardiomyopathy
I45.81 Long QT Syndrome
I44.3. Atrioventricular block
I49.5. Sick sinus syndrome
Z95.0 Presence of pacemaker
Z95.810. Presence of Defibrillator
Z95.818. Presence of ILR
Interrogation
Please Select
Pacemaker 93294 / 93296
ICD 93295 / 93296
EVICD 0578T / 0579T
ILR 93299
---
Programming
Please Select
Pacemaker
Defibrillator
ILR. 0650T
---
Date Completed
/
Month
/
Day
Year
Date
Submit
Should be Empty: