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Purpose

Record the patient's ECG.

ECG eCRF

Field Name

Description / Instructions

Format

Visit Date

The Visit Date is optional on this case report form. Hit the "Tab" key to leave it empty and move to the Date field.

DD-MMM-YYYY

Course #(d)

Indicates the course number the ECGs are related to based on their date and time.

5 digits

Day in Course(d)

Indicates the day since the beginning of course the cardiac ejection fraction results are related to based on their date and time.

5 digits

Date of Exam(m)

Enter the date the ECG was performed.

DD-MMM-YYYY

Time

Enter the time the ECG was performed.

HH(24):MM

QRSD Interval

Enter the QRS duration (QRSD) interval in milliseconds.

8 digits.

QT Interval

Enter the QT interval in milliseconds.

3 digits.

QTC Interval

Enter the QTC interval in milliseconds.

3 digits.

PR Interval

Enter the PR interval in milliseconds.

3 digits.

ECG Impression(m)

Select one of the following summary finding:
A - Abnormal
B - Borderline
N - Normal

Use pick list.

Rate(m)

Enter the patient’s pulse rate.

3 digits.

Rhythm(m)

Select one of the following rhythm finding:
A - Abnormal
N - Normal

Use pick list.

Arrhythmia Type

Select the patient’s arrhythmia type.

Use pick list.

P Wave

Select one of the following P Wave finding:
A-Abnormal
N-Normal

Use pick list.

QRS Complex

Select one of the following QRS Complex finding:
A-Abnormal
N-Normal

Use pick list.

ST Segment

Select one of the following ST Segment finding:
A-Abnormal
N-Normal

Use pick list.

Comments

Enter comments applicable to the ECG.

200 characters

Legend: (d) derived field, (m) RDC mandatory, (c) for CTEP reporting only.

Validations

Code

Description

Resolutions

ECG01

Date of Exam is in the future.

Enter a date that is equal to or prior to the current date.

Derivations

Code

Field Name

Description

ECG1001

Course #

Course number is derived based on the course initiation start dates and the Evaluation Date.

ECG1002

Day in Course

Number of days since the beginning of the course is derived from the course initiation start date and the Evaluation Date.