Cardiac Catheterization Procedure Note (Diagnostic)

Date/Time of Procedure: [Date and time]

Facility/Location: [Cath lab / Hybrid OR / Other location]

Primary Operator: [Name, credentials]

Assisting Physician(s): [Name(s), credentials] (Only include if applicable)

Anesthesia Provider: [Anesthesiologist / CRNA name] (Only include if MAC or general anesthesia used)

Procedure Start Time: [HH:MM]

Procedure End Time: [HH:MM]

High-Value Summary

• Indication(s): [Indication(s) for procedure]
• Procedure(s) performed: [RHC / LHC / Coronary angiography / LV ventriculography / Aortography / Pulmonary angiography / Other]
• Sedation/anesthesia: [Local only / Moderate sedation / MAC / General anesthesia]; Administered by: [Operator / Nursing under physician supervision / Anesthesia team]
• Vascular access: [Site and laterality] ([Ultrasound-guided / Landmark]); [Sheath size] Fr; Closure: [Manual / TR band / Closure device type]
• Anticoagulation: [Agent and dose]; ACT: [Value and time / Not applicable]
• Contrast: [Total volume] mL [Type]
• Radiation: Fluoroscopy time [Duration]; [Air kerma / DAP if available]
• Key hemodynamics: RA mean [Value] mmHg; PA [Systolic/diastolic/mean] mmHg; PAWP mean [Value] mmHg; CO [Value] L/min, CI [Value] L/min/m² ([Thermodilution / Fick]); PVR [Value] WU (Include only values actually obtained; if not obtained, state "Not obtained: [reason]")
• Coronary impression: [Normal coronaries / Summary of significant lesions by vessel with percent stenosis]
• Complications: [None / Event description and immediate management]
• Disposition: [Destination]; [Hemostasis protocol]; [Key medication changes]; [Follow-up plan]

Indications and Clinical Context

[Clinical question(s) addressed by procedure. Include pertinent comorbidities affecting risk or interpretation such as heart failure, CKD, prior CABG/PCI, valvular disease. Summarize relevant pre-procedure data: echocardiography, stress testing, and pertinent labs including hemoglobin if Fick method used and creatinine if contrast administered.]

Consent and Time-Out

• Informed consent obtained for [Procedures consented]
• Allergies reviewed; [Contrast reaction history and premedication if indicated]
• Correct patient, procedure, and site verified
• Anticoagulation status reviewed and appropriate for procedure
• Time-out completed with team present

Sedation and Monitoring

Sedation type: [Local only / Moderate sedation / MAC / General anesthesia]; Responsible provider: [Name and role]

• Medications given: [Agent, dose, route] (Refer to nursing record for complete time-stamped log)
• Monitoring: [Continuous ECG / Noninvasive BP / Invasive BP / Pulse oximetry / Capnography]
• Patient tolerance: [Well tolerated / Discomfort requiring additional sedation / Other]; Airway events or reversal agents: [None / Description]
• Sedation times: Start [HH:MM], Stop [HH:MM] (Only include if moderate sedation billed separately)

Vascular Access and Technique

• Access site(s): [Right / Left] [Radial / Ulnar / Femoral] artery; [Right / Left] [Internal jugular / Femoral / Antecubital] vein (Include ultrasound guidance if used)
• Technique: [Ultrasound-guided / Micropuncture / Standard Seldinger]; Sheath size(s): [Size] Fr
• Diagnostic catheters: [Catheter types and sizes used for coronary angiography and/or ventriculography]
• RHC catheter path: [Vein access → RA → RV → PA → Wedge position] (Only include if RHC performed)
• Difficulties encountered: [None / Spasm / Tortuosity / Inability to engage / Other]

Hemodynamic Data

(Enter values exactly as measured. If a measurement was not obtained, write "Not obtained: [reason]" rather than leaving blank.)

Parameter	Value
Heart rate (bpm)	[Value]
Systemic BP (mmHg)	[Systolic]/[Diastolic] (Mean: [Value])
RA mean (mmHg)	[Value] (end-expiration)
RV (mmHg)	[Systolic]/[Diastolic] (EDP: [Value])
PA (mmHg)	[Systolic]/[Diastolic] (Mean: [Value])
PAWP mean (mmHg)	[Value] (end-expiration)
LV (mmHg)	[Systolic] (EDP: [Value])
Aorta (mmHg)	[Systolic]/[Diastolic] (Mean: [Value])
Measured gradients	[Gradient type, value, and method if applicable]

Cardiac output: Method [Thermodilution / Direct Fick / Assumed Fick]; [Number] measurements averaged. (If Fick: Hgb [Value] g/dL; SaO2 [Value]% from [Arterial sample / Pulse oximetry]; SvO2 [Value]% from [PA sample].) CO: [Value] L/min; CI: [Value] L/min/m²

Derived calculations: SVR [Value] dyn·s·cm⁻⁵; PVR [Value] WU; TPG [Value] mmHg; DPG [Value] mmHg (Include only calculations relevant to clinical question and supported by obtained data)

Oximetry and Shunt Assessment

(Include this section only if shunt evaluation performed or clinically indicated)

Sampling Site	O2 Saturation (%)
SVC	[Value]
IVC	[Value]
Right atrium	[Value]
Right ventricle	[Value]
Pulmonary artery	[Value]
Systemic arterial	[Value]

Step-up assessment: [No step-up identified / Step-up consistent with left-to-right shunt at [atrial / ventricular / great vessel] level]

Qp/Qs: [Value] (Note: thermodilution cardiac output is unreliable in the presence of intracardiac shunts)

Angiographic Findings

Coronary Angiography

(Include only if performed)

• Dominance: [Right / Left / Codominant]
• Left main: [Normal / Lesion description with location, percent stenosis, and characteristics]
• LAD and diagonals: [Findings]
• LCx and obtuse marginals: [Findings]
• RCA, PDA, and PLV: [Findings]
• Bypass grafts: [Graft origins, targets, patency, and lesions] (Only include if grafts present)
• Imaging limitations: [None / Poor opacification / Vessel overlap / Inability to engage]

(For each significant lesion, note location, estimated percent stenosis, and relevant characteristics such as calcification, thrombus, or ostial involvement. Note TIMI flow if abnormal.)

Ventriculography

(Include only if performed)

• LV size: [Normal / Dilated / Other]
• LV function: [Qualitative assessment or estimated EF]
• Wall motion: [Normal / Regional abnormalities with location and severity]
• Mitral regurgitation: [None / Trace / Mild / Moderate / Severe]

(Reference LVEDP in hemodynamics section; do not duplicate here)

Aortography or Pulmonary Angiography

(Include only if performed)

• Indication: [Reason for imaging]
• Key findings: [Aortic regurgitation severity / Aortic anatomy / Pulmonary artery anatomy / Other findings]
• Imaging limitations: [None / Description if applicable]

Complications

[No immediate complications. / Description of complication(s) including: type (vascular, arrhythmia, hypotension, ischemia, contrast reaction, perforation), timing relative to procedure, objective findings, interventions performed, and current status. Distinguish procedural complications from expected disease progression when relevant.]

Hemostasis and Access Site Management

• Sheath removal: [Time or "end of procedure"]; Closure method: [Manual pressure / TR band / Closure device type]
• Hemostasis result: [Achieved / Oozing controlled with additional compression / Ongoing bleeding requiring intervention]
• Distal perfusion: [Intact with palpable pulses and warm extremity / Diminished requiring monitoring or intervention]
• Post-procedure restrictions: [Radial band deflation protocol / Femoral bedrest duration and positioning restrictions]

Post-Procedure Plan and Disposition

• Condition: [Stable / Hemodynamically stable / Other]
• Destination: [Recovery unit / Telemetry / ICU / Same-day discharge]; Monitoring: [Vitals and access site check frequency]
• Hydration: [IV fluids type and rate for renal protection / Not indicated]
• Labs: [Post-procedure labs ordered: hemoglobin, creatinine, ACT, other] (If results pending at note completion, state "Pending—will addend")
• Medications: [Antiplatelet or anticoagulation restart timing contingent on hemostasis; BP, antianginal, or diuretic adjustments based on findings]
• Follow-up: [Referring team notified; Outpatient appointments; Additional testing or referrals planned]
• Communication: Patient and [family / support person] informed of findings and plan