Procedure report structure for cardiology

A cardiac procedure report carries the indication, the access or protocol, the findings in the order the study produced them, any complication and how it was managed, an impression that answers the referring question, and a plan. The findings section is where the four cardiac studies differ: a stress echocardiogram reports haemodynamics, ECG and wall motion at rest and at stress, an angiogram reports vessel by vessel, a right and left heart catheterisation reports the pressure set and the derived calculations, and a transoesophageal echocardiogram reports structure by structure. aurii holds a template for each of the four, and dictation from the catheter laboratory or the echo suite drafts each section for the cardiologist to review and sign.

The shared spine is the same in the catheter laboratory and the echo suite. Each section states one thing.

The Medical Board of Australia's Good Medical Practice code asks for accurate, up-to-date, factual, objective and legible records in a form other health practitioners can understand. The spine is written to that standard: the referrer reads the indication and the impression together, and the next clinician reads the plan as written.

The stress echocardiogram template reports its findings in two states, rest and stress, for wall motion, ejection fraction and diastolic function, with the haemodynamics and the ECG recorded as their own sections beside them. Exercise and dobutamine studies use the same template, and the protocol section is where the two differ. There is no complications section. An adverse event is recorded under symptoms and under reason for termination, so the record shows what stopped the study. The impression answers one question, positive, negative or inconclusive for inducible ischaemia, and the plan states further workup or reassurance, medications and follow-up. The template page carries a negative exercise study and a positive dobutamine study as worked examples, both synthetic records.

The angiogram template reports its findings by vessel, one line per vessel and then dominance, so a normal vessel has a line as much as a diseased one. Access sits before the findings and the procedure after: route, side and sheath size on one side, vessels imaged, views obtained and contrast volume on the other. Complications is its own section. Where angioplasty and stenting followed in the same sitting, the procedure section carries the intervention and the flow restored, and the impression states the anatomy and disease severity. The plan states conservative management, further intervention or surgical referral, medications and follow-up.

The right and left heart catheterisation template reports its findings as a pressure set in a fixed order from the right atrium through to the left ventricle, then a calculations section for the output, index and resistances derived from it. Access records a vein and an artery, each with its sheath size. Coronary angiography has its own section, carrying the coronary findings where angiography was performed in the same sitting and stating that it was not performed where it was not. Complications is its own section. The impression gives the haemodynamic picture in a sentence, with the wedge pressure and the resistance that support it. The plan states medications, further procedures and follow-up.

The transoesophageal echocardiogram template reports its findings by structure, in a fixed order from the ventricles through the atria and each valve to the aorta and pericardium, and a normal structure is stated as normal. It has no access section and no complications section. Probe insertion, the sedation used and any complication during the study are recorded together under procedure. The indication names the question the study answers, whether endocarditis workup, left atrial appendage assessment before cardioversion or structural assessment before a procedure, and the impression carries the findings that matter with severity. The plan states surgical or medical management, further imaging, anticoagulation and follow-up.

For a cardiac study the record carries the indication, what was performed with site and side and the anaesthesia used, and the report the item requires with the date it was issued. In aurii the billing items for the study are captured at the bedside against the episode, for the practice to claim. The record each item family requires, and the adequate and contemporaneous records standard, are set out at What each MBS item requires in the record.

The report is signed by the cardiologist before anything is sent. Once signed, it leaves aurii as an HL7 v2 message over the Medical Objects network to the referrer's practice software, and the document reads sent, delivered or acknowledged as the acknowledgement returns. A referrer is reachable when they are listed on that network. A referrer who is not listed can be sent the signed report by email, which the clinician chooses per recipient. Email is not a secure-messaging channel. Within aurii, one patient record holds the procedure report with every note, letter, order, result and billing item in the admission, and the discharge summary is drafted from that record.

Before signing, check that the indication states the referrer's question, that every vessel, pressure or structure in the study has a line even where it is normal, that any complication is recorded with its management, that the impression states severity, and that the plan names who acts on each item and when. Confirm the referrer is listed on the Medical Objects network before the report is sent, and confirm the item descriptor for the date of service before the practice claims the item. Take advice from the practice's billing adviser where a descriptor has changed since the item was last claimed.