Using the Cardiac Monitoring Patient Intake Form

The procedures in this section are for clinicians who will enroll patients in VitalConnect cardiac monitoring. Clinicians should be familiar with the cardiac monitoring options.

To Perform Patient Intake

  1. Log on to VistaCenter as a user with privileges for completing Patient Intake (this will vary by organization).
  2. Select Menu > Patient Intake Form. The intake form displays on the screen.
  3. Fill out the form as follows:
    • Enter text in the fields using the keyboard.
    • Some fields (such as date fields) use pull-down menus to enable data entry.
    • Click to move from one field to the next, or use the Tab key to move to the next field. Use Shift+Tab to move to a previous field.
    • If your computer and browser have been configured to support voice input (for example, by using a product such as Dragon Medical), text fields may be filled by using dictation.

Required patient intake fields are marked in Red below. The form cannot be submitted unless required fields are completed.

Patient Information

Patient Name  Enter first name and last name.
Patient DOB  Enter date directly or use the pull-down calendar to select a date.
Patient MRN of SS Enter patient’s social security number or medical record number (per your organization’s procedures). The number used must be supported by the insurance provider.
Patient Gender Male or Female 
Next of Kin/Caregiver Full Name  If the patient has a caregiver (such as parent, spouse, or professional) who acts on behalf of the patient, enter full name here.
Street Address
Address Line 2
City, State, Zip
Enter patient’s address.
Primary Phone  Enter patient’s home phone.
Alternate Phone  Enter patient’s second phone number if one is available.

Insurance Information

Primary Insurance Provider

Use the pull-down menu to select a provider. If no insurance is available, select the None/Cash/Indigent option.

Note: To quickly search the list of providers, enter search text in the search field of the dropdown menu. 

Account Owner  Select Self, Spouse or Other.
Insurance ID
Insurance Group
Enter insurance ID number and group.
Upload Insurance Card Click the Choose File button to open an interface for uploading an image of the patient’s insurance card.
Primary Insurance Phone Enter insurance phone number.
Insurance Notes  Enter additional insurance details (if relevant to processing claim).
Secondary Insurance Info  If patient has secondary insurance, use the field to enter necessary details (provider, insurance number, and so on).

Prescriber Information

Prescriber Name Enter prescriber name. A pull-down menu may be available to select prescribers.
Preparer Name  Pre-entered based on the login name of the current VistaCenter user. Change if necessary.
Report Delivery Preference Use the pull-down menu to select the report delivery preference. See Report Delivery Preferences for information on creating and modifying delivery preferences.

Prescription Details

Diagnostic Codes Use the checkboxes to select the applicable diagnostic codes. More than one code may be selected. If code is not listed, select Other
2nd Diagnostic Codes  If additional diagnostic that apply, enter in this field.
Is the patient on an oral anti-coagulant? Select Yes or No.
Does the patient have an implanted pacemaker? Select Yes or No.
Ship monitoring kit to patient’s home? Select Yes or No.
Service Type  Select Extended Holter, MCT or Extended Holter NOW.

Mobile Cardiac Telemetry Details

This section displays when MCT is the selected service type.

Duration (Days) Select the service duration. 14 days is the default selection.
MCT Justifications Select the following options, if applicable:
  • Patient Symptom is too infrequent for Regular Holter
  • Patient may require actionable assessment or medical intervention that Regular Holter or Extended Holter does not provide
  • Onset and offset are critical and can’t be assessed by traditional event monitor
  • Rate history, heart rate variability, and arrhythmia burden are not available on traditional event monitor and are needed for patient assessment and/or treatment decisions
  • Patient needs near real-time monitoring for asymptomatic or patient triggered symptoms for actionable intervention not provided by Regular Holter or Extended Holter
  • Previous Holter (performed in the last 6 months) was not definitive for a treatment plan.
Has the patient had a Holter monitor in the previous 6 months?  Select Yes or No.
Additional Reports  Select optional Vital Signs report and/or 24-Hour Extended Holter.
Authorize Downgrade Select Yes (default) or No. If “Yes” is selected and insurance does not authorize coverage for MCT, service is automatically downgraded to CEM service.

Extended Holter Details

This section displays when Extended Holter or Extended Holter NOW is the selected service type.

Duration (Days) Select the service duration. 14 days is the default selection.
Additional Reports  Select optional Vital Signs report.

Monitoring Configuration

VistaPhone Device Name Use pull-down menu to select device name. Find the VistaPhone device name on the phone screen. If field is already completed, confirm that the device name is correct.
First/Second/Third/Fourth VitalPatch ID  Enter the last 6 digits/letters of the VitalPatch ID in these fields. The VitalPatch ID is found on the pouch label and on the adhesive backing of each patch.
Will there be a delay in applying VItalPatch to patient?  Enter a detailed response if the VitalPatch will not be applied immediately. Include anticipated date/time when monitoring will begin with explanation for delay.

Authorization and Finalization

Authorize Checkbox Check this field to certify that you are authorized to prescribe the service and that the prescription is medically necessary.


Click the Submit Patient Intake button when complete.

To View Patient Intake Information After Submission

  1. Access the Patient Census.
  2. Locate the patient name using the search and sort features of the Patient Census.
  3. In the Action column on the right side of the census table, click the Intake button for the patient. Patient intake details are shown in a panel on the right side of the page.

Clinical users cannot make changes to the patient intake form after submission. Some patient details may be changed using the Edit action in the Patient Census view. If changes are required (or performed) after intake is complete, contact the Cardiac Monitoring Service at idtf@vitalconnect.com to request (or confirm) changes.