*7.4. Documentation*

Each patient should have an individual record with sufficient information. Records must be completed after each session and should include [1,5]:


Functional capacity assessments and the patient's progress in exercise training should be documented.

Exercise test reports should include the test modality and protocol, test duration, heart rate and blood pressure values (at rest, maximal exercise, and following exercise cessation), functional capacity assessment, reason for test termination, rate of perceived exertion, ECG analysis, and clinical interpretation [6]. Cardiopulmonary testing reports should include gas exchange and ventilatory data at peak exercise and at ventilatory threshold (if determined) in absolute values and as percentages relative to a reference [7]. Exercise sessions documentation should be completed after each training session and should include the recording of vital signs and exercise parameters—i.e., exercise modality, intensity, total session duration, and potential clinical complications [5]. Administrative records (organizational chart, policies and procedures, qualification, and health records of personnel) should be kept in a safe location.

### *7.5. Medical Emergencies*

Properly conducted cardiac rehabilitation is safe, with a very low risk of major adverse events risk documented—i.e., 1 cardiac arrest per 116,906 patient-hours [8]. However, the potential for unpredictable complications still exists. Therefore, it is crucial for cardiac rehabilitation personnel to appropriately manage medical emergencies. All patients should be routinely screened before each exercise session regarding their change in clinical status, the presence of symptoms since the last training session, their change in heart rate and/or blood pressure, any gain in weight, or changes in their medication regimen.

Cardiac rehabilitation personnel must be familiar with the local protocol for specific emergencies—in particular, cardiac arrest—and chest pain [1]. Guidelines for managing emergencies should be included in program policies and procedures. All incidents must be adequately documented in the patient's chart. Emergency equipment should be immediately available to the exercise area. Emergency carts, resuscitation equipment, and medications must be checked regularly, and defibrillators must be checked daily before sessions commence [2]. All cardiac rehabilitation team members should have completed a valid basic life support course and at least one team member should have completed a valid advanced cardiac life support course. All emergency policies and procedures should be regularly reviewed by the program medical director, and regular emergency drills should be conducted.
