pcireport
1. Patient Demographics Card 1 of 6
2. Operator & Indication Card 2 of 6
3. Angiography Profile Card 3 of 6
4. Hardware Used Card 4 of 6
5. Outcomes & Advise Card 5 of 6
6. Doctor Signatures Card 6 of 6

CITY HEART HOSPITAL & RESEARCH CENTER

(Department of Cardiology & Cath Lab)

123 Medical Enclave, Hospital Road, City

Phone: +91-00000 00000 | Email: info@hospital.com

Website: www.hospital.com

Reg. / CIN No.: U28939XX2026PTC000000

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                    :
Name & Signature :
Date & Time :
IPD/PCIR/01
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