What the cardiac services requisition is for
This requisition orders two ambulatory tests at LifeLabs in Ontario. Holter monitoring records the heart rhythm continuously for the duration you choose. Ambulatory blood pressure monitoring records blood pressure over 24 hours while the patient goes about normal activities.
Who completes it
The ordering healthcare provider completes the Holter and ABPM sections and signs the form. The patient doesn’t complete any part. The second page is a set of patient instructions to hand over with the requisition.
How to fill in the requisition
Ordering provider and patient information
Enter your billing number, name, address, telephone and fax, and a copy-to clinician if needed. For the patient, give names as on the OHIP card, date of birth, sex, address, telephone, health card number and version.
Holter monitoring
Choose 72 hours, for example after an MI or stroke, 14 days, for example for atrial fibrillation, or other, and write in the duration. Then check the indications: abnormal ECG, palpitations, syncope, presyncope, chest pain or shortness of breath, fatigue, ruling out atrial fibrillation or flutter, atrial fibrillation rate control, unexplained stroke or TIA, post MI or valve procedure, medication effect, ventricular arrhythmia, sports cardiology, or pacemaker with its mode. Choose a duration that fits how often the symptom occurs.
Ambulatory blood pressure monitoring
Check 24-hour ABPM and an indication: a baseline for fluctuating, suspected, episodic or white-coat hypertension, suspected drug-resistant hypertension, hypotensive symptoms on treatment, or autonomic dysfunction. Tell the patient about the $85 fee before ordering.
Current medications and devices
List current medications, and check pacemaker or implanted cardiac defibrillator if present. Then sign and date the form.
Common reasons it’s delayed
- Other duration checked with no duration written in.
- No indication checked.
- Pacemaker checked without its mode.
- The patient arrived without the paper requisition.
Submitting and who pays
Give the patient the requisition and the instruction page. They book by calling 1-877-849-3637 and bring the paper requisition to the hook-up. ABPM carries an $85 fee that OHIP doesn’t cover, paid by the patient. Questions go to LifeLabs Cardiac Services at oncardiac@lifelabs.com.