Cath Lab Clinical Report Templates
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## Cath Lab Clinical Report Templates

The templates that comprise the Cardiac Catheterization Report are interconnected as shown in Figure A-7.

Figure A-7. Cardiac Catheterization Report Template Hierarchy

### Note

Figure A-7 shows the relationship of templates; it does not show the structural hierarchy of Content Items in the IOD.

### TID 3800 Cardiac Catheterization Report Root

The Cardiac Cath Report provides the overall clinical results of the catheterization procedure and interventions. In many cases, more detailed information is optionally available in other reports (Hemodynamic Measurements, Procedure Log, etc.). That information is collected and summarized here (and referenced when available).

When a Discharge Summary section (row 12) is included, this report template covers the full set of information required for submission to the ACC NCDR™ (version 2.0) registry.

### Note

1. The information required for such a submission must sometimes be reformatted from a single concept in these templates to two data elements for the registry, or vice versa.

2. This Template is expected to be used with the Basic Text SR or Enhanced SR IOD.3. This Cardiac Cath Report template is a baseline template within these SOP Classes that may be replaced; it is therefore in no sense binding for exchange of this type of report. It is solely an example of a possible encoding of the Cardiac Cath Report.

Type:

  Extensible

Order:

  Significant

Root:

  Yes

Table TID 3800. Cardiac Catheterization Report Root

| NL | Rel with Parent | VT | Concept Name | VM | Req Type | Condition | Value Set Constraint
--- | --- | --- | --- | --- | --- | --- | --- | ---
1 |  |  | CONTAINER | EV (18745-0, LN, "Cardiac Catheterization Report") | 1 | M |  | Root node
2 | > | HAS CONCEPT MOD | CODE | EV (121058, DCM, "Procedure reported") | 1 | M |  | DCID 3739 “Cath Procedure Type”
3 | > | HAS CONCEPT MOD | INCLUDE | DTID 1204 “Language of Content Item and Descendants” | 1 | M |  |
4 | > |  | INCLUDE | DTID 3601 “Procedure Context” | 1 | M |  |
5 | > | CONTAINS | INCLUDE | DTID 3802 “Cardiovascular Patient History” | 1 | U |  |
6 | > | CONTAINS | INCLUDE | DTID 3803 “Patient Presentation, Cath” | 1 | M |  |
7 | > | CONTAINS | INCLUDE | DTID 3806 “Cath Procedure” | 1 | M |  |
8 | > | CONTAINS | INCLUDE | DTID 3810 “Cardiac Catheterization Findings” | 1 | M |  |
9 | > | CONTAINS | INCLUDE | DTID 3807 “Percutaneous Coronary Intervention Procedure” | 1 | U |  |
10 | > | CONTAINS | INCLUDE | DTID 3809 “Other Interventional Procedures” | 1-n | U |  |
11 | > | CONTAINS | INCLUDE | DTID 3820 “Adverse Outcomes, Cath” | 1 | M |  |
12 | > | CONTAINS | INCLUDE | DTID 3824 “Summary, Cath” | 1 | M |  |
13 | > | CONTAINS | INCLUDE | DTID 3828 “Discharge Summary, Cath” | 1 | U |  |

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