Ask Dr. Z

I was wondering if there are specific requirements for what needs to be in the documentation of a cardiac cath. An outside resource disagrees with documentation requirements, and we are asking for your help to clarify. The physician includes the pre-procedure diagnosis, the findings and plan, contrast used, blood loss, fluro time, etc. This is an example of the main part of the procedure dictation: "Catheter: JACKY, JL4, PIG, 3DRC Sheaths: 5 FR, right radial artery Closure device: TR Band Dominance: right Pressures: Aorta: 136/75/101 LVEDP: 21 Coronaries: Left Main: Large caliber. Free of obstructive disease. LAD: Heavy proximal calcified plaque but no significant obstructive disease. Moderate caliber Diagonal. Free of obstructive disease. LCX: Moderate caliber, nondominant LCx. Moderate caliber OM. Free of obstructive disease. RCA: Moderate/large caliber. Dominant. No obstuctive disease. Moderate caliber PDA. Free of disease LVG: EF: 65% Findings: Calcified but nonobstructive coronary atherosclerosis Normal LV systolic function. EF 65% Mildly elevated LVEDP."