cardiac cath-left cardiac cath

pulin391

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When a left cardiac cath is performed with coronary and ventricular angiograms , is it necessary to have the actual contrast injection stated in the body of the report for both angios? If yes, can somebody direct me to the actual place where this rule written? Thanx:D
 

jtuominen

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Our cathlab docs typically set up their dictation in sections, where they specifically reference each vessel that they imaged and then have a seperate section for their ventriculogram results. Since you wouldn't be able to do a coronary angio or ventriculogram without contrast, I am thinking the best answer to you question would be "no" you don't have to state the contrast was injected, stating the procedures were performed may be sufficient (you can't have one without the other situation) but you would perhaps want to be sure that you have evidence that the coronary arteries were selectively engaged and that some reference was made to the results of the ventriculogram. Perhaps the one "back up" that we have in our dictation set up as well is that the doctors dictate the total contrast utilized during the procedure.

Here is a mock up of the style we use
PROCEDURE: Left Heart Catheterization with Coronary Angiogram and Left Ventriculogram

HISTORY:

RESULTS:
Left Main: the LMCA is normal
LAD: LAD has 50% to at most 60% narrrowing at the mid LAD
Left Circumflex: Normal
RCA: 20% narrowing in the proximal to midportion of the RCA

Left Ventriculogram: There is no mitral regurgitation. LVEDP is 27.

Total Contrast 320 ml of Optipray 350. Fluoro 7.0 minutes

CONCLUSIONS:

Hope this was helpful.
 
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