Transradial Coronary Procedure Access Record
Please complete all sections to accurately record the details of the transradial coronary access 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
Medical Record Number
*
Procedure Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Indication for Procedure
*
Please Select
Acute Coronary Syndrome
Stable Angina
Diagnostic Angiography
Percutaneous Coronary Intervention (PCI)
Other
Access Side
*
Right Radial
Left Radial
Other
Sheath Size (French)
*
Please Select
4F
5F
6F
7F
Other
Medications Administered at Access
Heparin
Verapamil
Nitroglycerin
None
Other
Closure Technique Used
*
Please Select
Manual Compression
Hemostatic Band
Other Device
Other
Were there any complications?
*
No
Yes (specify below)
If yes, please specify complications
Operator Name
*
First Name
Last Name
Assistant Name(s)
Additional Notes
Signature of Operator
*
Submit Record
Submit Record
Should be Empty: