Cardiac Monitoring 5-Lead Placement Checklist Form
Checklist for verifying correct 5-lead ECG placement and preparation before cardiac monitoring.
Patient Initials
*
Patient Room or Bed Number
*
Right Arm (RA) Electrode Placement Verified
*
Placed correctly (right subclavicular area)
Left Arm (LA) Electrode Placement Verified
*
Placed correctly (left subclavicular area)
Right Leg (RL) Electrode Placement Verified
*
Placed correctly (right lower abdominal area)
Left Leg (LL) Electrode Placement Verified
*
Placed correctly (left lower abdominal area)
Chest (V) Electrode Placement Verified
*
Placed correctly (precordial position per protocol)
Skin Preparation Completed (shaved, cleaned, dried as needed)
*
Preparation completed
Lead Connections and Signal Quality Checked
*
All leads connected and signal quality confirmed
Reviewer Name and Confirmation
*
First Name
Last Name
Submit Checklist
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