Recommended Chart Documentation

At the MGH we do the following to document all of our interrogations
  1. Place programmer reports into the patient’s paper record (using hole puncher on cart) or electronically with a thumb drive
  2. Enter a procedure note in the medical record defining what you did to the patient’s device. Ideally you will also enter any pertinent lead and battery and mode information that might assist other clinicians who will be taking care of the patient.
  3. Maintain a logbook with a patient sticker—again recording the following:
    1. The Device type (Pacer, ICD, CRT-P or CRT-D)
    2. Manufacturer
    3. Base mode and actual mode if mode switched
    4. Type of accelerometer if device in DDDR
    5. What you did