I am just curious and was looking for another opinion. Do you feel these reports are adequate for an OP reports for cardiac cath. Is this sufficient information for coding purposes and compliance. At this facility the op report will look like one of the or the other. Most often the look like sample two and can get very difficult to translate with complex intervention peripheral or coronary. Sample two appears to be a copy of the intra procedure tech log. I do not feel these are adequate however physician and facility believe they are in compliance with this documentation.
Sample #1
Procedure:R&LHC
*********Stent DES to Cx 2.5 x 26 Resolute, post-dilated proximal portion to 3.4 mm
*********Stent DES to mid RCA 2.5 x 18 Resolute
Operator:*********Doctor
History:New onset angina
******Abnormal stress test with large infero-lateral reversible defect
Indication:*******Same
Findings:*********LMCA - normal
LAD - proximal stent, 50% ISR, 60% stenosis on distal edge of stent. Stent is across D1
Cx - 30% ostial, 95% mid in-stent
RCA - 75% mid focal lesion
Normal LV systolic function with EF 60%
Normal right heart cath pressures
************
RecsIntegrelin infusion 12 hours
*ASA 81, clopidogrel 600 today, then 75 daily for one year
*Atorvastatin 20 daily
Likely home tomorrow
Sample #2
Procedure Date: 1/1/2016
*
*
*
Procedure Name*** By
*
RIGHT AND LEFT HEART CATH*** CORONARY ANGIOGRAPHY***
LEFT HEART CATH***
LEFT VENTRICULOGRAPHY**
*RIGHT COMMON FEMORAL ANGIOGRAPHY WITH STARCLOSE CLOSURE****
*
INDICATIONS:
*
abnormal stress test
dyspnea
chest pain
*
*
Indications: abnormal stress test, dyspnea, chest pain
*
with CP, DOE, and mitral regurgitation
*
HISTORY AND RISK FACTORS:
Hypertension:
Prior CHF:
Chronic Lung Disease:
*
CARDIAC FINDINGS:
*
Left Main 0 % Lesion
Prox LAD 10 % Lesion
Mid/Distal LAD, Diag Branches 30 % Lesion
Circ, OMs, LPDA, LPL Branches 30 % Lesion
RCA, RPDA, RPL, AM Branches 30 % Lesion
*
LV FINDINGS:
LV Gram - 40 % EF
Global Hypokinesis - Mild
Depressed LV systolic function - Moderate
DOMINANCE:
Dominance: Right
*
*
OTHER FINDINGS:
*
*
*
LOCAL ANESTHETIC:
Local anesthetic to right groin region with Lidocaine 2%
PROCEDURAL APPROACH:
Access: 7 fr Sheath inserted using the Seldinger technique into the
right femoral vein
Access:6 fr* Sheath inserted using the Seldinger technique into the
right femoral artery
PROCEDURE NOTES:
LV ventriculography performed
LCA angiography performed in multiple views
RCA angiography performed in multiple views
Swan catheter advanced
Pressures recorded
Saturations obtained
Simultaneous Pressures recorded
Swan removed
Right femoral angiography performed to evaluate for closure device
Right femoral angiography performed to evaluate for closure device
Left V gram - 12 ml/sec for 36 ml total
CATHETER PLACEMENT
POST SHEATH STATUS:
Sheath pulled and closure device deployed for hemostasis
venous sheath Pulled manual compression for 10 mins
POST SITE STATUS:
Site Status: No immediate procedural complications noted
Site Status: No bleeding / hematoma - Right groin - tegaderm applied
Site Status: Wound Class- 1=Clean
Site Status: No bleeding / hematoma - Right groin - monitor site.
small pea sized hematoma at injection site
CONTRAST:
Used for the procedure Isovue370 76 ml's
*
DIAGNOSTIC EQUIPMENT:
*
Wire inserted
Swan catheter advanced
Pressures recorded
Saturations obtained
Simultaneous Pressures recorded
Swan removed
Catheter advanced** - 6 Fr. Pigtail
pigtail Catheter exchanged for* - 6 Fr. JL 4
jl4* Catheter exchanged for* - 6 Fr. FR 4
jr4 Catheter removed over wire
Wire removed
ABBOTT 6Fr StarClose-SE - Qty: 1* Each Part #: 84124
*
MEDICATIONS:
{Narcotics/Sedation} Versed 1 mg IV
{Narcotics/Sedation} Fentanyl 25 mcg IV
{Narcotics/Sedation} Versed 1 mg IV
{Narcotics/Sedation} Fentanyl 25 mcg IV
Nitro 200 mcg IC
Nitro 200 mcg IC
Nitro 200 mcg IC
Oxygen:* 3 L/min via nasal cannula
*
*
Date/Time
*
AIR REST
ECG***** 2016-01-11* 08:25:02
ECG***** 2016-01-11* 08:25:07
AO* 179/115* (140)* SA*** 2016-01-11* 08:46:03
RA* 18/22* (18)* SV*** 2016-01-11* 08:46:46
RA* 14/18* (13)***** 2016-01-11* 08:47:45
RV* 57/7,* 16***** 2016-01-11* 08:48:24
PA* 53/23* (37)* PA*** 2016-01-11* 08:49:08
PW* 34/39* (33)* PV*** 2016-01-11* 08:50:58
LV* 170/8,* 20***** 2016-01-11* 08:51:38
*
POST NITRO
LV* 153/5,* 13***** 2016-01-11* 08:54:59
PW* 27/24* (22)* PV*** 2016-01-11* 08:54:59
LV* 156/6,* 13***** 2016-01-11* 08:55:07
PW* 21/23* (20)***** 2016-01-11* 08:55:07
LV* 166/9,* 15***** 2016-01-11* 08:56:01
PWp* 35/42* (38)***** 2016-01-11* 08:56:01
LV* 162/6,* 13***** 2016-01-11* 08:56:08
PAp* 43/28* (36)***** 2016-01-11* 08:56:08
LV* 163/8,* 13***** 2016-01-11* 08:56:45
PA* 41/14* (31)* PA*** 2016-01-11* 08:56:45
LV* 167/9,* 16***** 2016-01-11* 08:57:12
PAp* 44/9* (27)***** 2016-01-11* 08:57:12
LV* 167/9,* 15***** 2016-01-11* 08:57:19
RVp* 40/7,* 10***** 2016-01-11* 08:57:19
LV* 165/6,* 13***** 2016-01-11* 08:57:36
RAp* 10/12* (9)***** 2016-01-11* 08:57:36
LVp* 153/8,* 14***** 2016-01-11* 09:00:19
AOp* 157/91* (117)***** 2016-01-11* 09:00:26
AOp* 157/97* (122)***** 2016-01-11* 09:06:04
AOp* 155/93* (119)***** 2016-01-11* 09:06:21
Type*** SV*** CO (l/m)*** CI (l/m/*** HR*** Date/Time
*
AIR REST
Fick*** 81.00*** 5.59*** 2.61*** 69*** 2016-01-11* 08:25:02
Valve*** Area (c*** P-P/ms*** Date/Time
*
POST NITRO
Mitral*** 0.00*** 8.7 mn/447 ms
7.0 pk/447 ms*** 2016-01-11* 08:55:07
Aortic*** 0.00*** 10.5 mn/50 ms
2016-01-11* 09:00:19
*
*
CONCLUSIONS:
*
Mild non-obstructive CAD
Mild to moderate LV systolic dysfunction with EF
2 to 3+ MR by LV angio
Elevated wedge pressure and PA pressure but the systemic pressure
was also elevated.* Lowering BP with NTG did result in much improved
PA and wedge pressures.
*
*
RECOMMENDATIONS:
*
Need to be more aggressive with BP
TEE to look at mitral valve apparatus
If the mitral valve is structurally normal would consider adding LV
pacing
Would check MUGA
*
Sample #1
Procedure:R&LHC
*********Stent DES to Cx 2.5 x 26 Resolute, post-dilated proximal portion to 3.4 mm
*********Stent DES to mid RCA 2.5 x 18 Resolute
Operator:*********Doctor
History:New onset angina
******Abnormal stress test with large infero-lateral reversible defect
Indication:*******Same
Findings:*********LMCA - normal
LAD - proximal stent, 50% ISR, 60% stenosis on distal edge of stent. Stent is across D1
Cx - 30% ostial, 95% mid in-stent
RCA - 75% mid focal lesion
Normal LV systolic function with EF 60%
Normal right heart cath pressures
************
RecsIntegrelin infusion 12 hours
*ASA 81, clopidogrel 600 today, then 75 daily for one year
*Atorvastatin 20 daily
Likely home tomorrow
Sample #2
Procedure Date: 1/1/2016
*
*
*
Procedure Name*** By
*
RIGHT AND LEFT HEART CATH*** CORONARY ANGIOGRAPHY***
LEFT HEART CATH***
LEFT VENTRICULOGRAPHY**
*RIGHT COMMON FEMORAL ANGIOGRAPHY WITH STARCLOSE CLOSURE****
*
INDICATIONS:
*
abnormal stress test
dyspnea
chest pain
*
*
Indications: abnormal stress test, dyspnea, chest pain
*
with CP, DOE, and mitral regurgitation
*
HISTORY AND RISK FACTORS:
Hypertension:
Prior CHF:
Chronic Lung Disease:
*
CARDIAC FINDINGS:
*
Left Main 0 % Lesion
Prox LAD 10 % Lesion
Mid/Distal LAD, Diag Branches 30 % Lesion
Circ, OMs, LPDA, LPL Branches 30 % Lesion
RCA, RPDA, RPL, AM Branches 30 % Lesion
*
LV FINDINGS:
LV Gram - 40 % EF
Global Hypokinesis - Mild
Depressed LV systolic function - Moderate
DOMINANCE:
Dominance: Right
*
*
OTHER FINDINGS:
*
*
*
LOCAL ANESTHETIC:
Local anesthetic to right groin region with Lidocaine 2%
PROCEDURAL APPROACH:
Access: 7 fr Sheath inserted using the Seldinger technique into the
right femoral vein
Access:6 fr* Sheath inserted using the Seldinger technique into the
right femoral artery
PROCEDURE NOTES:
LV ventriculography performed
LCA angiography performed in multiple views
RCA angiography performed in multiple views
Swan catheter advanced
Pressures recorded
Saturations obtained
Simultaneous Pressures recorded
Swan removed
Right femoral angiography performed to evaluate for closure device
Right femoral angiography performed to evaluate for closure device
Left V gram - 12 ml/sec for 36 ml total
CATHETER PLACEMENT
POST SHEATH STATUS:
Sheath pulled and closure device deployed for hemostasis
venous sheath Pulled manual compression for 10 mins
POST SITE STATUS:
Site Status: No immediate procedural complications noted
Site Status: No bleeding / hematoma - Right groin - tegaderm applied
Site Status: Wound Class- 1=Clean
Site Status: No bleeding / hematoma - Right groin - monitor site.
small pea sized hematoma at injection site
CONTRAST:
Used for the procedure Isovue370 76 ml's
*
DIAGNOSTIC EQUIPMENT:
*
Wire inserted
Swan catheter advanced
Pressures recorded
Saturations obtained
Simultaneous Pressures recorded
Swan removed
Catheter advanced** - 6 Fr. Pigtail
pigtail Catheter exchanged for* - 6 Fr. JL 4
jl4* Catheter exchanged for* - 6 Fr. FR 4
jr4 Catheter removed over wire
Wire removed
ABBOTT 6Fr StarClose-SE - Qty: 1* Each Part #: 84124
*
MEDICATIONS:
{Narcotics/Sedation} Versed 1 mg IV
{Narcotics/Sedation} Fentanyl 25 mcg IV
{Narcotics/Sedation} Versed 1 mg IV
{Narcotics/Sedation} Fentanyl 25 mcg IV
Nitro 200 mcg IC
Nitro 200 mcg IC
Nitro 200 mcg IC
Oxygen:* 3 L/min via nasal cannula
*
*
Date/Time
*
AIR REST
ECG***** 2016-01-11* 08:25:02
ECG***** 2016-01-11* 08:25:07
AO* 179/115* (140)* SA*** 2016-01-11* 08:46:03
RA* 18/22* (18)* SV*** 2016-01-11* 08:46:46
RA* 14/18* (13)***** 2016-01-11* 08:47:45
RV* 57/7,* 16***** 2016-01-11* 08:48:24
PA* 53/23* (37)* PA*** 2016-01-11* 08:49:08
PW* 34/39* (33)* PV*** 2016-01-11* 08:50:58
LV* 170/8,* 20***** 2016-01-11* 08:51:38
*
POST NITRO
LV* 153/5,* 13***** 2016-01-11* 08:54:59
PW* 27/24* (22)* PV*** 2016-01-11* 08:54:59
LV* 156/6,* 13***** 2016-01-11* 08:55:07
PW* 21/23* (20)***** 2016-01-11* 08:55:07
LV* 166/9,* 15***** 2016-01-11* 08:56:01
PWp* 35/42* (38)***** 2016-01-11* 08:56:01
LV* 162/6,* 13***** 2016-01-11* 08:56:08
PAp* 43/28* (36)***** 2016-01-11* 08:56:08
LV* 163/8,* 13***** 2016-01-11* 08:56:45
PA* 41/14* (31)* PA*** 2016-01-11* 08:56:45
LV* 167/9,* 16***** 2016-01-11* 08:57:12
PAp* 44/9* (27)***** 2016-01-11* 08:57:12
LV* 167/9,* 15***** 2016-01-11* 08:57:19
RVp* 40/7,* 10***** 2016-01-11* 08:57:19
LV* 165/6,* 13***** 2016-01-11* 08:57:36
RAp* 10/12* (9)***** 2016-01-11* 08:57:36
LVp* 153/8,* 14***** 2016-01-11* 09:00:19
AOp* 157/91* (117)***** 2016-01-11* 09:00:26
AOp* 157/97* (122)***** 2016-01-11* 09:06:04
AOp* 155/93* (119)***** 2016-01-11* 09:06:21
Type*** SV*** CO (l/m)*** CI (l/m/*** HR*** Date/Time
*
AIR REST
Fick*** 81.00*** 5.59*** 2.61*** 69*** 2016-01-11* 08:25:02
Valve*** Area (c*** P-P/ms*** Date/Time
*
POST NITRO
Mitral*** 0.00*** 8.7 mn/447 ms
7.0 pk/447 ms*** 2016-01-11* 08:55:07
Aortic*** 0.00*** 10.5 mn/50 ms
2016-01-11* 09:00:19
*
*
CONCLUSIONS:
*
Mild non-obstructive CAD
Mild to moderate LV systolic dysfunction with EF
2 to 3+ MR by LV angio
Elevated wedge pressure and PA pressure but the systemic pressure
was also elevated.* Lowering BP with NTG did result in much improved
PA and wedge pressures.
*
*
RECOMMENDATIONS:
*
Need to be more aggressive with BP
TEE to look at mitral valve apparatus
If the mitral valve is structurally normal would consider adding LV
pacing
Would check MUGA
*