Date of Device Check
/
Month
/
Day
Year
Date
Patient Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
Baseline 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 (s)
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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
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
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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
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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 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)
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Billing
Diagnosis 1
Please Select
Diagnosis 2
Please Select
Diagnosis 3
Please Select
Interrogation
Please Select
Pacemaker 93294 / 93296
ICD 93295 / 93296
EVICD 0578T / 0579T
ILR 93299
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Programming
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Pacemaker
Defibrillator
ILR
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Date Completed
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Month
/
Day
Year
Date
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