e-Requisition

Electronic Cardiac Requisition — Malawi

Patient details

• Full name:

• National ID / Hospital number:

• Shorten.Date of birth:

• Sex:

• Weight (kg):

• Height (cm):

• Contact phone:

• Address / District:

Referring clinician

• Name:

• Position / Department:

• Facility:

• Contact phone:

• Email (optional):

• Date of request:

Clinical indication / history

• Presenting complaint (brief):

• Relevant history (cardiac risk factors, prior cardiac diagnoses, surgeries, rheumatic fever, hypertension, diabetes, HIV status if relevant):

• Current medications:

• Allergies:

• Vital signs (BP, HR, RR, Temp if available):

• Relevant physical findings (murmur, oedema, JVP, pulse irregularity):

Requested investigations / services (tick or write)

• Echocardiogram

  • Type: Transthoracic (TTE) / Focused / Paediatric / Transoesophageal (TEE) — specify

  • Urgency: Routine / Urgent (within 72 hours) / Emergency (immediate)

  • Clinical question (what to assess: systolic function, valve lesions, chamber size, pericardial effusion, congenital lesion, prosthetic valve, etc.):

• Electrocardiogram (ECG)

  • Resting 12-lead ECG

  • Telemetry / rhythm strip

  • Exercise ECG / Stress test — specify protocol and indication

  • Urgency: Routine / Urgent / Immediate

• Cardiology consult

  • Type: Inpatient / Outpatient / Teleconsultation

  • Urgency: Routine / Urgent / Same day

  • Reason for consult (diagnosis, management question, pre-op assessment, anticoagulation advice, heart failure management, arrhythmia, syncope, paediatric cardiology, peripartum cardiology, other):

Additional tests or notes

• Blood tests recommended (tick as appropriate): Full blood count, Urea & electrolytes, Creatinine, Liver function, Cardiac enzymes (troponin), BNP/NT-proBNP, Blood cultures, HIV test, RHD screening (if relevant), INR

• Imaging recommended: Chest X-ray, Doppler studies, CT/MRI cardiac — specify

• Other: Specify any mobility, infection control, language, or consent issues

Pre-test requirements

• Fasting required (yes/no) — specify duration for stress tests or TEE

• Anticoagulation instructions (hold warfarin/DOAC? specify duration)

• IV access required: yes/no

• Pregnancy status (for female patients of childbearing potential): known pregnant / not pregnant / unknown

Prior investigations attached / available

• Attach prior ECG: yes/no — date

• Attach prior echo: yes/no — date and report available

• Other: chest X-ray, labs — dates

Safety and consent

• Confirm informed consent obtained for procedure: yes/no

• Infection control precautions: TB / COVID-19 / MRSA / other — specify

• Interpreter required: yes/no — language:

Referrer signature

• Name:

• Signature:

• Date/time:

For departmental use (to be completed byOrder echocardiography, ECG and patient care — connect with us.

Echo: Transthoracic and stress echo by experienced sonographers. Same-day or next-available appointments.

ECG: Resting 12‑lead, Holter and event monitors. Rapid interpretation and secure reports.

Patient care: Pre‑test instructions, comfortable clinic, clear result explanations, coordinated follow‑up/referral.

Reporting: Timely electronic reports; clinician‑to‑clinician consults for urgent cases.

Book: Call bookings, email patient services, or use our secure portal to request tests and upload referrals.

Prepare: Bring photo ID, health card, medication list and referrals/notes. Ask about fasting, meds or device (pacemaker/ICD) compatibility before your visit.

Referrals: Include indication, history and urgency. We accept electronic or paper referrals and triage urgent cases.

Contact details and booking hours available from patient services.