Cardiac Catheterization Procedure Note (Interventional)

Cardiac Catheterization Procedure Note (Interventional)

(Omit header fields or role lines that do not apply. For any required field that is unknown, enter "Unknown/Not documented" rather than leaving blank.)

Date/Time: [Procedure date] [Start time] – [End time]

Location: [Cath lab room]

Patient: [Name], [DOB], [MRN]

Primary Operator: [Name, credentials]

Assistant(s)/Fellow(s): [Name(s), credentials] (Omit line if none)

Anesthesia Provider: [Name, credentials] (Omit line if none)

Referring Physician: [Name]

Urgency: [Elective / Urgent / Emergent] (If activation applies: [STEMI activation / NSTEMI pathway / cardiogenic shock / other])

High-Value Summary

• Indication: [Indication for procedure]
• Procedures: [Diagnostic and interventional components completed]
• Key findings: [Culprit lesion and critical anatomy]
• Interventions: [Lesion(s) treated with brief device strategy] (One line per lesion)
• Results: [Per-lesion pre/post stenosis (%) and TIMI flow (0–3)]
• Hemodynamics: [Key values if relevant, e.g., LVEDP, gradients]
• Totals: [Contrast volume mL; fluoroscopy time min; radiation indices if available]
• Complications: [None immediate / brief event list]
• Disposition: [Destination, support devices, access hemostasis protocol]

Pre-Procedure Assessment

Presenting syndrome: [Syndrome and timeline] (e.g., STEMI, NSTEMI, stable angina, cardiogenic shock; timing relative to symptom onset)

Pre-procedure testing: [Testing prompting catheterization] (Stress testing, CTA, echo, biomarkers—include only if relevant)

Pertinent comorbidities: [Risk modifiers] (CKD with creatinine and dialysis status; diabetes; heart failure; shock/arrest; bleeding risk; contrast allergy with prophylaxis)

Pre-procedure labs: [Relevant labs] (Platelets, INR if anticoagulated, hemoglobin, creatinine/eGFR. If critical data missing, state "Not available at time of procedure" with mitigation strategy.)

Antithrombotic status: [Agents and last dose timing] (Antiplatelet and anticoagulation agents with bridging if applicable)

Consent and Verification

Consent: [Informed consent obtained / Emergency exception per institutional policy]

Time-out: [Pre-procedure verification and time-out completed with cath lab team] (If deviation occurred, document circumstances)

Sedation

Sedation type: [None / minimal / moderate / deep / general anesthesia / MAC]

Administered/supervised by: [Provider role(s) and name(s)]

Sedatives/analgesics: [Agent – total dose and route] (List each agent)

Events: [None / airway or hemodynamic events described] (If separate anesthesia record exists, summarize relevant events here)

Procedure Details

Procedures Performed

Diagnostic: [Coronary angiography / LHC / LV gram / RHC] (List all performed)

Interventions: [PCI / thrombectomy / atherectomy / intravascular imaging / physiology assessment / lithotripsy / valvuloplasty] (List all performed)

Mechanical support: [IABP / Impella (model) / temporary pacer / none] (List devices placed)

Vascular Access and Hemostasis

• Access site(s): [Right / left] [radial / femoral / brachial]; sheath size: [Fr]
• Ultrasound guidance: [Used / not used]
• Crossover access: [No / Yes – reason]
• Hemostasis: [TR band / manual pressure / closure device type] – [Successful / unsuccessful]

Anticoagulation and Procedural Medications

• Anticoagulant: [Heparin / bivalirudin / other] – [Dose/strategy]; ACT: [Values with times]
• Intracoronary medications: [Nitroglycerin / adenosine / verapamil / other – dose] (Include only if clinically significant)
• Hemodynamic support: [Vasopressors/inotropes – agent and dose] (If required)
• Antiarrhythmics: [Agent and dose] (If administered)

Hemodynamics

(Include pre- and post-intervention values when gradient comparison is relevant. If indicated hemodynamics not obtained, state "Not obtained" with reason.)

Measurement	Pre-intervention	Post-intervention	Units
AO systolic/diastolic/mean	[Value]	[Value]	mmHg
LVEDP	[Value]	[Value]	mmHg
RA mean	[Value]	[Value]	mmHg
RV systolic/diastolic	[Value]	[Value]	mmHg
PA systolic/diastolic/mean	[Value]	[Value]	mmHg
PCWP mean	[Value]	[Value]	mmHg
Cardiac output/index	[Value]	[Value]	L/min or L/min/m²; [method]
O₂ saturations	[Values by site]	[Values by site]	% (Include shunt calculation if performed)
Transvalvular gradient	[Value]	[Value]	mmHg; [valve specified]

Findings

Coronary Angiography

• Dominance: [Right / left / co-dominant]
• Left main: [Lesion description with % stenosis / normal]
• LAD and diagonals: [Lesion locations and %; notable features]
• LCx and obtuse marginals: [Lesion locations and %; notable features]
• RCA and branches: [Lesion locations and %; notable features]
• Grafts: [Graft type and target; patency; lesions] (Include only if grafts present)
• Culprit vessel: [Identified vessel/segment / culprit uncertain] (For ACS presentations)

Intravascular Imaging and Physiology

(Include only if performed)

• Modality: [IVUS / OCT / FFR / iFR] – [Vessel/segment assessed]
• Key findings: [MLA; plaque morphology; stent expansion/apposition; ischemic threshold values]
• Impact on decision-making: [How findings guided therapy]

Interventions (PCI)

Lesion Overview

Lesion #	Target vessel/segment	ACS culprit	Strategy	Outcome
[#]	[Vessel/segment]	[Yes / no / uncertain]	[Balloon only / DES / atherectomy + DES / other]	[Successful / partial / failed]

(Add rows for each lesion treated or attempted)

Per-Lesion Documentation

(Repeat this block for each attempted lesion)

Lesion [#]: [Vessel/segment]; [Native / graft / ISR / CTO / bifurcation]

Pre-Intervention: [Stenosis %]; TIMI flow: [0/1/2/3]; [Characteristics: thrombus, calcification severity, tortuosity, bifurcation type]

Guide/Wire: [Guide catheter]; [Guidewire(s)]

Devices and Technique:

• Predilation: [Balloon size (diameter × length mm)] at [max atm]
• Specialty devices: [Atherectomy / thrombectomy / lithotripsy] – [Device name] [Parameters] (If used)
• Stent(s): [Type, brand/model]; [Diameter × length mm]; [Deployment pressure atm]
• Post-dilation: [Balloon size mm] at [max atm]
• Optimization imaging/physiology: [IVUS/OCT/FFR/iFR findings] (If performed)

Device Identifiers: (Capture per institutional policy; if not captured, state "UDI not captured")

Implanted device	Identifier (UDI/lot/serial/catalog)
[Device name/model]	[Identifier]

Post-Intervention Results: Residual stenosis: [%]; Final TIMI flow: [0/1/2/3]; Gradient: [Pre/post values] (If applicable). Final impression: [Successful / partially successful / failed – reason if not successful]

Procedure Totals

Metric	Value	Units
Contrast volume	[Value]	mL
Fluoroscopy time	[Value]	minutes
Reference air kerma	[Value / unavailable]	mGy
Dose-area product	[Value / unavailable]	Gy·cm²

Complications

Immediate complications: [None / list events]

(This section must always be completed. If events occurred, document below:)

• Event: [Perforation / dissection / no-reflow / access hematoma / contrast reaction / arrhythmia / other]
• Phase: [Diagnostic / wiring / predilation / stenting / post-dilation / hemostasis]
• Evidence: [Objective findings]
• Actions: [Interventions taken]
• Outcome: [Patient status at end of case]

Post-Procedure Status and Disposition

• Hemodynamics: [Stable / unstable]; Rhythm: [Sinus / paced / atrial fibrillation / other]; Oxygenation: [Room air / supplemental O₂ / ventilated]
• Access site: [Hemostasis achieved]; [Distal pulses intact]; [TR band status/protocol if radial]
• Destination: [Recovery / telemetry / ICU]; Support: [None / intubated / vasopressors / MCS]
• Immediate imaging: [ECG / CXR / echo / access ultrasound] (If performed)

Post-Procedure Plan

• Monitoring: [Level of care]; access site checks [frequency]
• Antiplatelet regimen: [Agent(s), loading dose, maintenance dose, planned duration] (Or "deferred to rounding team")
• Anticoagulation: [Restart/hold plan and timing] (If applicable)
• Labs: [CBC / BMP / troponin] – [Timing per protocol]
• Hydration: [IV fluids type/rate / not indicated]
• Follow-up imaging: [Echo / vascular imaging] (If indicated)
• Follow-up: [Appointment timing]; [Cardiac rehab referral] (If applicable)

Communication

• Patient/family: [Informed of results – summary of discussion]
• Referring physician/primary team: [Notified – method and time]
• Consultation: [Not required / requested – consultant and plan]

Attestation

[Operator electronic signature, credentials, date, time]

(Late entries or addenda must be labeled with date, time, and reason.)