Pump Templates


Download the Perfusion Record Template

Dear AmSECT Colleague:

Over the past several years, the perfusion community has contributed a great deal of information to the Perfusion Quality Committee. The outstanding response to the manpower survey resulted in the AmSECT Scope of Practice. The Scope of Practice generated the AmSECT Guidelines for Perfusion Practice, and with input from the perfusion community, The Guidelines for Ancillary Perfusion Practices including IABP, Ventricular Assistance, ECLS, Myocardial Protection, and Isolated Limb Perfusion.

The most recent efforts of the Committee has generated a prototype perfusion record. It is included in this mailing and hopefully it will be of help to those of you looking to revise your perfusion record. An introduction to the record and an explanation of how the Committee arrived at the data points to be recorded is included. For those of you who prefer graphic type records, it is possible to remove the portion of the record you will not use and insert a chart type record. The entire record is done in Microsoft Excel.

At this time, the Perfusion Quality Committee would like to request that you submit any IABP and/or Cell Salvage records or ideas for information you think needs to be included on such records. Please send the records to the AmSECT National Headquarters. A completed record helps the Committee in compiling the information and would be most helpful.

Over the past several weeks, the Perfusion Quality Committee has received inquiries about “Pump Standby” cases and what to do with the pump. We would like to hear from the perfusion community . . . What do you do? Please take a few moments and let us know your protocol regarding standby cases.

  • Is the pump set up for standby cases?
  • Is the pump in the room and set up for standby cases?
  • Is the pump primed for standby cases?
  • How long do you keep a dry set up pump?
  • How long do you keep a primed pump?

You can reply via e-mail to the AmSECT Perfusion Quality Committee. Once compiled the information will be disseminated to the perfusion community.

On behalf of the Committee, past and present, I would like to thank everyone in the perfusion community who has helped the Committee by submitting the documents we have requested, by critiquing the information that has been sent out for review, and those who have taken the time to answer surveys. Your input is invaluable and certainly appreciated.

Susan Haubert, Chairman
Perfusion Quality Committee


The purpose of this project is to provide perfusionists with a comprehensive instrument for documenting parameters that reflect the conduct of cardiopulmonary bypass. This template is intended as a tool and not as a standard. It has evolved from the Perfusion Practice survey, Essentials and Guidelines for Perfusion, and from a statistical analysis of the perfusion records submitted from the world-wide perfusion community. These templates are meant to be flexible to accommodate institutional conventions and requirements. Each institution’s perfusion protocols should drive decisions about specific fields and values included in the record. The goals of improved documentation are:

  • increased awareness and safety
  • accurate representation of service delivered
  • internal review / risk management
  • medico-legal defense
  • compliance / benchmarking / JCAHO / standardization

All medical records should clearly describe the clinician’s actions and patient responses to those actions. Format should:

  • encourage completeness and accuracy with pre-defined data fields, as opposed to more subjective narrative forms. (This also allows the maximum amount of documentation in the least amount of time and attention)
  • allow data to flow logically from one action to the next
  • be clear, legible, easy to read and interpret
  • be updated periodically to reflect changes in practice

Other considerations:

  • Only hospital-approved abbreviations are permitted on the record.
  • CLIA and state laboratory laws require that normal lab values be stated on the record.
  • Guidelines of all accrediting agencies must be followed.
  • All parameters which are monitored should be recorded.
  • Records must be signed.
  • As much as possible, events should be recorded as they occur.
  • All entries must be based on fact, rather than interpretation, hearsay or opinion.

In 1996 AmSECT requested that members submit their perfusion records to be used in the development of a template for perfusion documentation. There were 158 records received. Common data elements were tabulated and divided into 16 categories. There were 207 parameters entered as fields. The frequency of use of each parameter was counted and calculated as a percentage of all records. The template is a reflection of the results of this analysis, with a few codicils:

  • records submitted may not reflect some current practices (arterial line pressure and SvO2 are examples of data which are routinely monitored but not as frequently recorded)
  • some laboratory and coagulation test results may be recorded elsewhere and do not show up as fields on the perfusion record, and are therefore under-represented by the statistics.
  • patient addressograph may record certain elements which are therefore not recorded by the perfusionist (i.e. age, gender, ID number), so these may also be under-represented statistically.

The results of the analysis lead to some conclusions about the current state of perfusion documentation:

  • Current documentation does not reflect that the standards established in the AmSECT’s Essentials and Guidelines for Perfusion Practices, are being met.
  • Statistics suggest that many perfusionists are not documenting and/or monitoring anticoagulation management, which should be within their purview.
  • There are emerging areas of perfusion service which need expanded documentation, such as the rapidly evolving techniques of myocardial protection.
  • A standard template cannot meet the needs of all teams, necessitating its adaptation for each institution.

This project was approached by analyzing many records. This allowed the best elements and formats of a number of records to be used to create an effective document, that better meets the previously stated goals for improved record-keeping. Greater than 80% of the records were in chart form, as opposed to graphic format. Both styles will be offered as examples. The core elements have been incorporated into both styles. Some of the common elements include:

  • The “comments” section allows for the documentation of events not in the pre-defined fields.
  • The “baseline / Pre-op” column and the “Pre-CPB / Post-hep” column allow for a complete documentation of adequate heparinization before bypass.
  • The expanded cardioplegia section allows for accurate, legible, and complete reporting of the delivery of myocardial protectants. The “formula” columns can be adapted from “hi/lo” to reflect more complex medication regimens. The “site” columns can be changed to a coded format to specify any number of delivery sites (i.e. LAD, ostium, coronary sinus). The codes for these parameters can be included on the record. (see Reverse Front Page for example).
  • The Reverse First Page includes: regulatory-mandated normal clinical lab values; acceptable hospital abbreviations; cardioplegia formulas; codes for coded entries; units of measure; and, if desired, the pre-bypass checklist.
  • Summary section of page 1 allows for additional fields which may be case or institution-specific.


Click on this link and you will be prompted to save the file called pump.exe to your hard drive. Save the compressed file to your hard drive and double-click on it to extract the three files. One file is a Microsoft Word document called intro.doc and the other two are Microsoft Excel files called pump1.xls & pump2.xls. If you have any problems with this process, please e-mail AmSECT National Headquarters