Documentation for Pacemaker Care Accurate clinical documentation is critical, especially during emergency situation. This article gives a detailed view on best documentation practices for pacemaker care and the use of ECG monitoring. Medical Transcription Services
Pacemaker is a cardiovascular implantable electronic device (CIED) that sends small electrical impulses to the heart muscle to maintain a suitable heart rate or to stimulate the lower chambers of the heart (ventricles). This device may be also used to treat fainting spells (syncope), congestive heart failure and hypertrophic cardiomyopathy. Depending upon the condition of the patient, this device is implanted permanently or used temporarily (in emergency situations). In all cases, accurate documentation via medical transcription is essential for providing better care for patients undergoing pacemaker implementation. Let’s take a detailed into the documentation requirements for pacemaker care.
Important Documentation Elements The crucial documentation elements are as follows:
Type of pacemaker used
Date and time of pacemaker placement
Physician who inserted the device
Reason for placement
Pacemaker settings
Patient’s LOC and vital signs, noting which arm you used to take the blood pressure reading
Complications (infection, chest pain, pacemaker malfunction or arrhythmias)
Interventions performed and their results (for example, using X-rays to verify correct electrode placement and information obtained from a 12-lead ECG)
You should obtain and include rhythm strips in the medical record during the following times:
Before, during and after the placement of pacemaker
Change in pacemaker settings anytime
The patient receives treatment resulting from a pacemaker complication anytime
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If the patient has a transcutaneous pacemaker (a temporary means used for pacing a patient's heart during a medical emergency), you should make sure the following details are documented.
Reason for using this kind of pacing
Time when the pacing started
Location of the electrodes
ECG Monitoring and Documentation An electrocardiogram (ECG) is the recording of the electrical activity of the heart, which can point out the changes in the patient’s condition and aid diagnosis. The electrodes placed at specific points on the skin detect the heart’s electrical impulses during conduction and displayed them as a graphic waveform on an ECG machine or cardiac monitor. You can study the patient’s condition by monitoring the waveform. Either 12lead or continual ECG monitoring can be performed. However, patients on continual ECG monitoring need to be nursed in high observation areas where alarms are easily heard.
So, why is ECG monitoring important for pacemaker care? By monitoring pacemaker function with ECG monitoring, you can find out the problems with the pacemaker (for example, improper sensing, failure to pace and so on). For example, compared to permanent pacemakers, temporary transve1nous pacemakers are associated with a higher risk of loss of capture. This is because temporary transvenous lead wires are stiffer than permanent lead wires in order to facilitate rapid insertion from remote venous access points and lack of active and passive fixation mechanisms of permanent leads. So, it is very important to monitor the patients with temporary pacemakers until pacing is no longer necessary and the device is either removed or replaced with a permanent device.
When the ECG monitoring continues, you should document the following:
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Capture
Sensing rate
Intrinsic beats
Competition of paced and intrinsic rhythms
The accuracy of documentation for pacemaker care is critical, especially when it comes to emergency care. In order to avoid copy-paste issues with EMR documentation, you can follow an integrated approach of EMR and transcription in which the recordings are transcribed and reviewed after which the transcribed data is populated into the relevant EMR fields.
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800-670-2809