PLACE LABEL HERE
CARDIOLOGY EXERCISE STRESS TEST (ETT)
ASSESSMENT
Date:
Weight:
 Inpatient
Stated weight _______ lbs, actual weight _______ kg
___________________
Cardiac Enzymes Ordered? No Yes
Room #: _________
 Outpatient Phone #: __________________________
Troponin(initial): _________ Troponin-90min: _________ Troponin-6hr: _________
Referring Physician: _________________________________ Primary Care Physician:___________________________________
Allergies: ___________________________________________________________________________________________________
Indication for Stress Test: _____________________________________________________________________________________
Current Medications: See Home Medicines List (Medication Reconciliation) or see In-Patient chart
History
 CP, MI, HF, HTN, PTCA, CABG
 Diabetic
 Asthma, COPD
 Smokes ______________________
 Pacemaker/ICD
 Other: _______________________
PMHR _________100%
________90%
HR
Initial Assessment
Hand-off process

Alert & Oriented

Report received from:

Resp Reg & Non-labored
_____________ @ __________am/pm

Oxygen in use

Report given to:

Skin warm, dry & pink
_____________ @ __________am/pm

Chest Pain (score ________)

BP______ HR_______
Medication and Dose
Time
Initials
_______85%
BP
Pain (0-10)
Supine
Standing
____ Min
____Min
____Min
____Min
____Min Post
____Min Post
Time
Comments/Symptoms/Vital Signs:
Procedure:
Post Procedure Chest Pain (score ______________)
Under the supervision of ____________________________, the patient exercised on a treadmill for ______minutes & ______seconds
of a Bruce Mod Bruce Other _________ protocol with a resting heart rate of ______ bpm to a heart rate of ______bpm which
was ______% of the PMHR.
The blood pressure went from a resting value of _____ / _____ to a peak value of _____ / _____.
The test was stopped due to: THRA
Fatigue
Chest Pain/Tightness
SOB
HTN
Other: _________________
The resting EKG showed: ______________________________________________________________________________________
The EKG at peak exercise showed: _______________________________________________________________________________
Comments:________________________________________________________________________________________________
________________________________________
Name of Technician(s)
______________________________________________
PA / Cardiologist supervising procedure Signature
________________________________________
Date/Time RN Signature
_______________________________________________
Date/Time Interpreting Physician Signature PID Number
*1-20019*
FORM 1-20019 REV. 08/2011
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