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PERFORMANCE CHECKLIST
LEVEL 3: NURSING CARE MANAGEMENT 112 S-

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PERFORMING CLINICAL ELECTROCARDIOGRAPHY (ECG)

Name: _________________________________________ Date:

Rating:

Instruction: Rate the student properly after the student practiced the procedure and ready to
perform the return demonstration.

Legend: 4 - Action is correct, complete, and performed in proper order and timing.
3 - Action is correct, complete, but not in order and performed action slowly or
very fast.
2 - Action is incorrect and incomplete and performs action very slowly or very
fast.
1 - Action is not performed but mentioned.
0 - Did not perform and did not mention the step in the procedure.

CI’s
Performance Criteria 4 3 2 1 0
Remarks

Knowledge (30%)

1. Describe an electrocardiogram (ECG) and its

indications.
2. Identify the different parts of an
electrocardiogram.
3. Enumerate the different waveforms to be
checked when obtaining an electrocardiogram
(ECG).
4. Identify the proper placements of the different
leads of the electrocardiogram ECG).
5. Identify the materials needed for obtaining an
electrocardiogram (ECG).
Skills (35%)

PREPARATION:
1. Verify the written prescription or order of the
physician.
2. Determine rationale for obtaining ECG – baseline
assessment or diagnostic.
3. Prepare the needed equipment.

4. Introduce self and verify the client’s identity

using agency protocol.
5. Explain the procedure to the client, if possible.

6. Observe universal precautions. Perform hand

hygiene and observe other appropriate infection
prevention procedures.
7. Prepare the client.
a. Remove metals in contact with the patient’s
body and electronic devices.
b. Remove or reposition patient’s clothing to
expose only patient’s chest and arms. Keep
pelvis and thighs covered.
c. Place the patient in supine position.

d. Instruct patient to lie still without talking and

to not cross legs.
e. Clean and prepare skin by wiping sites with
alcohol. Chest hair might be clipped if large
amounts are present.
8. Place the leads on appropriate sites.
For limb/extremities leads, place one lead on
each extremity, avoiding any bony
prominences.
a. RA – Right Wrist
b. LA – Left Wrist

c. LL – Left Ankle

d. RL – Right Ankle

For chest/precordial leads, place one lead on each

appropriate site.
a. V1 – 4th intercostal space, right sternal
border
b. V2 – 4th intercostal space at left sternal
border
c. V3 – Midway between V2 and V4

d. V4 – 5th intercostal space, midclavicular line

e. V5 - Left anterior axillary line, at level of V4

horizontally
f. V6 – Left midaxillary line, at level of V4
horizontally
9. Turn on ECG machine, enter required
demographic information, and obtain
electrocardiogram tracing.
10. Disconnect leads and wipe off excess electrode
paste from chest.
11. Perform the necessary documentation such as
when the electrocardiogram was obtained (name,
age, sex, date and time) and the attachment of the
 rhythm strip in the patient’s chart per agency
protocol.
Attitude (35%)

1. Reports to RD area on time.

2. Greets the CI and introduces self.

3. Presents self for return demonstration with properly

fixed hair, short unpolished nails and in
complete school uniform.
4. Has initiative in preparing materials for the
procedure and resourceful with the available
materials.
5. Performs the procedure confidently.

6. Manages time effectively, performs the

procedure not too slow/ not too fast.
7. Observe proper decorum and maintains a respectful
and calm atmosphere throughout the
procedure.
8. Listen attentively to comments/ suggestions of CI
and accept criticisms well.
9. Communicate concerns politely and tactfully to
CI.
10. Performs after care of materials.

Student’s Remarks:

Student’s Signature Printed Name & Signature of CI