PCI Preparation and Outcome Log
Document the preparation steps and outcomes for each Percutaneous Coronary Intervention (PCI) procedure.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Procedure Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Operator/Physician Name
*
First Name
Last Name
Indication for PCI
*
Please Select
STEMI (ST-Elevation Myocardial Infarction)
NSTEMI (Non-ST-Elevation Myocardial Infarction)
Unstable Angina
Stable Angina
Other
Pre-Procedure Checklist (select all completed steps)
*
Informed consent obtained
Allergies checked
Renal function assessed
Fasting confirmed
IV access established
Pre-medication administered
Other
Medications Administered Before PCI (select all that apply)
Aspirin
Clopidogrel
Heparin
Glycoprotein IIb/IIIa inhibitor
Other
Target Vessel(s) Treated
*
Left Anterior Descending (LAD)
Left Circumflex (LCx)
Right Coronary Artery (RCA)
Other
Devices Used During PCI (select all that apply)
Balloon catheter
Drug-eluting stent
Bare-metal stent
Atherectomy device
Other
Complications During or After PCI
None
Bleeding
Arrhythmia
Vessel dissection
Contrast reaction
Other
Immediate Outcome of PCI
*
Please Select
Successful reperfusion
Partial reperfusion
Failed reperfusion
Other
Additional Notes or Comments
Submit Log
Should be Empty: