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Primary Care Physician
15-20 minutes

Holter Monitor Report

The s10.ai Holter Test Summary template is an all-encompassing documentation resource tailored for general practitioners and healthcare providers to efficiently record and analyze Holter monitor data. This template features sections for patient demographics, Holter monitor specifics, and in-depth findings including rhythm analysis, ectopy, and ischemia detection. Perfect for summarizing Holter monitoring outcomes, it aids in assessing cardiac symptoms such as palpitations and dizziness. By ensuring comprehensive data capture, this template delivers a clear and precise overview of the patient's cardiac health, motivating clinicians to adopt this tool for enhanced patient care and streamlined workflow.

2,858 uses
4.5/5.0
E
Evelyn Chen
Template Structure

Organized sections for comprehensive clinical documentation

(Throughout this note, bold all section headings and text written within asterisks "")
- Patient Name: [First and last name of patient] (include preferred first name or nickname in quotations between the first and last name, if provided)
- DOB: [Date of birth of patient] (include full date in MM/DD/YYYY format)
- Age/Gender: [Age in appropriate unit (years, months, weeks, days)], [Gender: male or female] (use years if over 1 year, months if less than 1 year, weeks if more than 2 months old, days if less than 2 weeks old.)
- Primary Care Provider Type: [Type "Pediatrician", "Primary Care Physician", or "Primary Care Provider"] (choose based on whether provider is a pediatrician, MD/DO, or otherwise; only include if mentioned)
Primary Care Practice: [name of primary care practice, referring group] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Referring Provider: [name of referring provider] (format as Dr. then first and last name if provider is an MD or DO, otherwise as first name and last name comma credentials: NP, PA, etc. if the referring provider is an MD or DO and is the same person as the primary care provider then the name format should be “Dr.” then last name) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Holter Monitor Details
- Holter Monitor Type: [Medium-Term, Short-Term, Long-Term, or Monitored Telemetry Holter] (select based on information provided; if mentioned, write in narrative form: "Holter monitor worn from [start date] to [end date]")
- Indication: [Reason for Holter monitoring] (succinct narrative form; only include if explicitly mentioned)
- Total Diagnostic Time: [Total monitoring time and artifact time] (use alpha-numeric form; only include if explicitly mentioned)
- Total Beat Count: [Total beat count] (use numeric form; only include if explicitly mentioned)
Holter Monitor Results
1. Predominant Rhythm Findings: [Predominant rhythm description, heart rate range, average heart rate] (only include if explicitly mentioned)
2. Supraventricular Ectopy Findings: [Supraventricular ectopy description] (if normal or not mentioned, print "No Supraventricular ectopy, no tachycardia.")
3. Ventricular Ectopy Findings: [Ventricular ectopy description] (if normal or not mentioned, print "No Ventricular ectopy, no ventricular tachycardia.")
4. AV Block or Sinus Pause Findings: [AV block or sinus pause description] (if normal or not mentioned, print "No AV block or significant sinus pauses.")
5. Ischemia Findings: [Evidence of cardiac ischemia and related findings] (if normal or not mentioned, print "No evidence of cardiac ischemia.")
6. Symptoms and Diary Events:
- [Specific symptoms described and diary events entered] (if none mentioned, print "No specific symptoms were described. No diary events entered." If multiple events, list each separately as bulleted items with "- ")
7. Overall Holter Result: [Summary interpretation of Holter study] (if normal, print "Normal Holter"; only include if explicitly mentioned)
Report Completed by: [Provider Name] (format as Firstname Lastname, credentials)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
Sample Clinical Note

Example of completed documentation using this template

- Patient Name: John "Johnny" Smith  
- DOB: 03/15/1980  
- Age/Gender: 44 years, male  
- Primary Care Provider Type: Primary Care Physician  
Holter Monitor Details  
- Holter Monitor Type: Holter monitor worn from 10/25/2024 to 10/28/2024  
- Indication: Assessment of palpitations and dizziness  
- Total Diagnostic Time: 72 hours, 2 hours artifact time  
- Total Beat Count: 350,000  
Holter Monitor Results  
1. Predominant Rhythm Findings: Sinus rhythm with occasional premature atrial contractions, heart rate range 55-110 bpm, average heart rate 75 bpm  
2. Supraventricular Ectopy Findings: No supraventricular ectopy, no tachycardia.  
3. Ventricular Ectopy Findings: No ventricular ectopy, no ventricular tachycardia.  
4. AV Block or Sinus Pause Findings: No AV block or significant sinus pauses.  
5. Ischemia Findings: No evidence of cardiac ischemia.  
6. Symptoms and Diary Events:  
   - Palpitations noted on 10/26/2024 at 14:00  
   - Dizziness reported on 10/27/2024 at 09:30  
7. Overall Holter Result: Normal Holter  
Report Completed by: Dr. Emily Johnson, MD
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive Holter Monitor Report Template is designed to streamline the documentation process for healthcare professionals, ensuring accurate and efficient recording of cardiac monitoring data. With clearly defined sections such as Patient Name, DOB, Age/Gender, and Primary Care Provider Type, clinicians can easily input patient demographics. The template also includes detailed fields for Holter Monitor Details and Holter Monitor Results, allowing for precise documentation of monitoring type, indications, diagnostic time, and beat count. Clinicians can capture rhythm findings, ectopy, AV block, ischemia, and symptoms with ease, ensuring a thorough analysis of cardiac health. The template concludes with a section for the Report Completed by the provider, ensuring accountability and traceability. By adopting this template, healthcare providers can enhance the accuracy of cardiac assessments, improve patient care, and streamline clinical workflows.
Frequently Asked Questions

Common questions about this template and its usage

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Holter Monitor Report