1. Patient Demographics Card 1 of 6

Patient Name

Age

Sex

Reg. No. (IPD/OPD)

Cath No.

Date

Address

2. Operator & Indication Card 2 of 6

Operator

Indication

3. Angiography Profile Card 3 of 6

Lesion 1

Lesion 2

Lesion 3

Route

Aortic Pressure

Contrast

Gp 2b/3a Inhibitor

4. Hardware Used Card 4 of 6

Guiding Catheter

Guide Wire Used

Pre Dilatation

Stent

Post Stent Dilatation

5. Outcomes & Advise Card 5 of 6

End Result

Conclusion

Advise

6. Doctor Signatures Card 6 of 6

Doctor 1

Doctor 2

Doctor 3

CKS HOSPITALS

(A Unit of CKS Medicare Pvt. Ltd.)

F-98 A, Road No. 6, VKIA, Jaipur

Pin Code : 302013, Phone : 0141-3313233

Website : www.ckshospitals.com

CIN No.: U28939RJ1980PTC002080

PERCUTANEOUS CORONARY INTERVENTION REPORT

Name :

Reg. No. :

Date :

Address :

Age :

Sex :

Cath No. :

OPERATOR :

INDICATION :

ANGIOGRAPHY PROFILE :

Lesion 1 :

Lesion 2 :

Lesion 3 :

Route :

Aortic Pressure :

Contrast :

Gp 2b/3a Inhibitor :

HARD WARE USED

Guiding Catheter :

Guide Wire Used :

Pre Dilatation :

Stent :

Post Stent Dilatation :

End Result :

Conclusion :

Advise :