Guide · checked October 2026
How to write a cath lab procedure report
A cath lab procedure report should record the indication, the procedure performed, access and closure, medications given, findings, devices used with their lot numbers, contrast volume and radiation dose, any complications and the plan, so that it serves the clinical record, IR(ME)R and the national PCI audit at once.
A practical structure
- Indication
- Procedure(s) performed
- Access: site and sheath size
- Medications administered, including procedural anticoagulation
- Findings (written by the operator)
- Devices used, with make, size and lot
- Contrast volume and radiation dose (dose-area product and fluoroscopy time)
- Complications recorded
- Closure method and device
- Plan (written by the operator)
This is a common layout and the one Cath Copilot's demo template uses; your department's template takes precedence.
Why dose belongs in the note
IR(ME)R 2017 Schedule 2(j) requires employer's procedures for carrying out and recording a clinical evaluation for each exposure, including, where appropriate, factors relevant to patient dose. DHSC's guidance says dose factors should go in the recorded clinical evaluation, and that stored exposure data should allow a later dose estimate. In a cath lab the procedure report is usually where that evaluation lives.
Keep it consistent with the audit
BCIS says more than 100 data items are recorded per PCI procedure for the national audit, covering the patient, the reason for presentation, technique and equipment, and in-hospital outcomes, and that the data are entered by each centre. When the note and the audit return are built separately, they drift: a contrast volume, a stent length or a closure device ends up different in each. Writing both from the same validated values avoids that.
Common problems
- Two sources disagree (for example the injector and the nursing record on contrast) and nobody notices.
- Complications left blank, which reads as "none" when nobody stated it.
- Device lot numbers missing, which makes recall searches slow.
Where Cath Copilot fits
Cath Copilot drafts the procedure note in the local template from validated timeline events, with a citation to the source record on every statement. Findings and Plan stay with the operator. Where sources disagree, such as 145 mL on the injector and 140 mL in the nursing record, the mismatch must be confirmed before the note can be signed, and signing locks while any statement has no support. The confirmed values also feed the audit return and the handover.
Cath Copilot is a prototype on synthetic data only. It is not a medical device and is not for clinical use.
Questions
Should radiation dose be in the cath lab report?
IR(ME)R requires procedures for recording a clinical evaluation of each exposure including, where appropriate, factors relevant to patient dose, and DHSC's guidance says dose factors should go in that evaluation.
Who writes the findings?
The operator. Cath Copilot drafts the record-based sections and leaves Findings and Plan to the operator.
Sources
Official pages, checked October 2026. Guidance changes, so check the current version before you rely on it.
General information for healthcare managers and clinical teams, checked October 2026. It is not legal, regulatory or clinical advice; follow the current official guidance and your organisation's own policies. No patient data is used in these examples. Cath Copilot is a prototype running on synthetic data only. It is not a medical device and is not for clinical use. It recommends, drafts, and routes; it never diagnoses, orders, or decides. A clinical safety and information-governance process precedes any use with real patient data.