Catheterization Procedure Report on Coronary Angiography

Name:

Family Name:

Birth Date:

Age:

CATH No. : (xxxx/xx) Date: 26 June 2018

Sterile Nurse

Bio-Engineer

Referring Physician/Institution:

Risk factors and specific information (free text):

Preliminary investigations (CATH No.):

Vascular Access: Arterial: Venous: Venous Cannula: Right Arm Left Arm

Indication: (free text):

Fluro time : min	X-Ray dosis (cGray/cm2):	Contrast media (ml):

Medication: UHF Heparin i.v/i.a (I.U.).:	Nitro (mg):	other:

Hemodynamics:

Pressures ( mm Hg) –S/D	Mean Pressure ( mm Hg)	O2-Saturation ( %)
Left Ventricle (LV)	/
LV end-diastolic (LVedd)
Aorta Asc. (AOa)	/
Aorta Desc. (AOd)	/

Ventriculography left:	EF (%):	EDV (ml):	ESV ml	LV-Anatomy (free text):

Mitral-Valve:

Right Coronary:	(free text):

Left Coronary:	(free text):

Findings:	(free text):

Diagnostic Findings: #1 #2 #3

Other (free text):

Treatment: Other (free text):

Instructions for the Ward: Time to loosen the pressure bandage: (hh:mm) . Leave bed: (hh:mm)

Drink 2 liter water or tee within two hours. More (free text):

First operator

Signature

Second operator

Signature