RUMAH SAKIT UMUM DAERAH PASAR REBO RM-RU 18

Jl. Let. Jend. TB. Simatupang No. 30

Telp. 8400109, 8401127 Fax 8411159
JAKARTA 13760

ANALISA ELEKTRO KARDIOGRAM

Tanggal: : ............................................... Nomor R M : :

Nama : ................................................ L/P Umur : ..................... thn
Berat Badan : ...................... kg Tekanan Darah : ................. mmHg
Catatan klinik dan pengobatan :

1. Frekwensi denyut jantung : ............................................................................................................. per menit

2. Irama jantung : ..............................................................................................................................
3. Gelombang P : ..............................................................................................................................
4. Interval P-R : ..............................................................................................................................
5. Komplek QRS : ..............................................................................................................................
Interval : ..................................................................................................................... detik
Sumbu listrik : .................................................................................................................. derajat
Konfigurasi : ..............................................................................................................................
VAT : V1 ............................................... detik, V6 ............................................... detik
Corrected Q interval : ..................................................................................................................... detik
Transitional zone : ..............................................................................................................................
Elec heart position : ..............................................................................................................................
6. Segmen S T : ..............................................................................................................................
7. Gelombang T : ..............................................................................................................................
Konfigurasi : ..............................................................................................................................
Sumbu listrik : .................................................................................................................. derajat
QRS – angle : .................................................................................................................. derajat
8. Gelombang U : ..............................................................................................................................
9. Lain-lain : ..............................................................................................................................
10. Kelainan ECG yang ditemukan :
......................................................................................................................................................................................................
......................................................................................................................................................................................................
.......................................................................................................................................................................................................
Kesimpulan :
1. EKG normal
2. EKG dalam batas normal
3. EKG pada ”border line”
4. EKG patologis menunjukkan ...............................................................................
5. EKG patologis dengan adanya tanda-tanda keadaan : .................................................
6. EKG patologis non spesifik

Anjuran :
Dokter Pemeriksa,

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