OF520

Electrocardiographic Record

Agency
GSA
Revision
Rev. 8/2001
Fillable fields
45
Pages
1
Official source
GSA form page
Checked
October 20, 2026
Fill OF520 online
Page 1 of form OF520

Optional Form 520 (OF 520): Electrocardiographic Record

Optional Form 520 (OF 520), Electrocardiographic Record, is a one-page medical record printed as OPTIONAL FORM 520 (REV. 8/2001). The form names no issuing agency; GSA hosts it in its forms library.

The top of the form records the request: whether there was a previous ECG, emergency or routine, bedside or ambulant, the clinical impression, medication, age, sex, height, weight and B.P., with the signature of the ward physician. The middle holds the reading: rhythm, axis deviation (QRS), rates, PR, QRS and QT intervals, P waves, QRS complexes, R-ST segment, T waves, the leads and a summary. The bottom identifies the patient, the sponsor and the facility.

The footer says Attach Tracings to SF 507, and the top says AUTHORIZED FOR LOCAL REPRODUCTION. You can fill it out free in your browser on this page and download the result without an account.

Top of page 1 of Optional Form 520 (OF 520): Electrocardiographic Record, as printed by GSA

What's on OF 520

Request details

PREVIOUS ECG yes or no, EMERGENCY or ROUTINE, BEDSIDE or AMBULANT, CLINICAL IMPRESSION, MEDICATION, AGE, SEX, HEIGHT, WEIGHT and B.P.

Rhythm, rates and intervals

RHYTHM, AXIS DEVIATION (QRS), RATES split into AURIC. and VENT., INTERVALS for PR, QRS and QT, and P WAVES.

Waveform findings

QRS COMPLEXES, R-ST SEGMENT and T WAVES, each with its own box.

Leads

UNIPOLAR EXTREMITY LEADS (Specify) and PRECORDIAL LEADS (Specify), each with a large open area.

Summary and signature

SUMMARY, SERIAL CHANGES, AND IMPLICATIONS, marked Continue on reverse, then the ECG number, signature of physician and date.

Identification blocks

Relationship to sponsor, sponsor's name and ID number (SSN or Other), department or service, hospital or medical facility, records maintained at, patient's identification, register number and ward number.

The single page runs from the request at the top to the identification blocks at the bottom.

How to fill out OF 520

  1. 1

    Identify the patient

    For typed or written entries, the form asks for the patient's name (last, first, middle), ID No or SSN, sex, date of birth and rank or grade, plus register and ward numbers.

  2. 2

    Complete the request area

    Check previous ECG, emergency or routine and bedside or ambulant, then enter the clinical impression, medication and the patient's measurements. The ward physician signs and dates.

  3. 3

    Record the findings

    Fill in rhythm, axis deviation, rates, intervals, P waves, QRS complexes, R-ST segment and T waves, and specify the extremity and precordial leads.

  4. 4

    Write the summary and sign

    Enter the summary, serial changes and implications, then the ECG number, the physician's signature and the date.

  5. 5

    Attach the tracings

    The footer says Attach Tracings to SF 507.

The form prints no step-by-step instructions. These steps follow its blocks.

Why fill Form OF520 on indox

You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.

  • Fill the form right in your browser, no software to install
  • Free to fill and free to download, with no account
  • The official blank straight from the GSA, not a copy someone retyped
  • Works on a phone, tablet or computer

Where it goes and what the form says

Where it goes

The PDF prints no filing address. It is labeled Medical Record, and the RECORDS MAINTAINED AT box names where the records are kept.

ECG tracings

The footer says Attach Tracings to SF 507.

More space

The summary box says Continue on reverse. The PDF GSA hosts has a single page.

Copies

The top of the form says AUTHORIZED FOR LOCAL REPRODUCTION.

Related forms

Who completes OF 520?

  • The ward physician

    The request area at the top has a SIGNATURE OF WARD PHYSICIAN line with a DATE box, next to the patient's age, sex, height, weight and B.P.

  • The signing physician

    Below the summary, a second line reads SIGNATURE OF PHYSICIAN, with an ECG NO. box and a DATE box.

  • The patient and sponsor

    The patient is identified at the bottom by name, ID No or SSN, sex, date of birth and rank or grade. The form also asks for the relationship to sponsor, the sponsor's name and the sponsor's ID number.

  • The hospital or medical facility

    The bottom rows name the department or service, the hospital or medical facility, where the records are maintained, and the register and ward numbers.

The form prints two physician signature lines and identification blocks for the patient and the facility. It does not say who fills in each finding.

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Questions about Form OF520

Who issues OF 520?

The form names no issuing agency. GSA hosts it in its forms library, and the PDF is printed as OPTIONAL FORM 520 (REV. 8/2001).

Where do the ECG tracings go?

The footer of the form says Attach Tracings to SF 507.

Who signs OF 520?

The form has two signature lines: SIGNATURE OF WARD PHYSICIAN in the request area, and SIGNATURE OF PHYSICIAN below the summary, each with a date.

What patient details does OF 520 ask for?

For typed or written entries, the name (last, first, middle), ID No or SSN, sex, date of birth and rank or grade, plus register and ward numbers and sponsor details.

Is there room to continue the summary?

The summary box says Continue on reverse. The PDF hosted by GSA has one page.