Angiography Vascular Access Record Form
Please complete this form to document the details of the angiography vascular access procedure.
Patient Initials
*
Procedure Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Procedure Location
*
Please Select
Cath Lab
Operating Room
Radiology Suite
Other
Access Site
*
Please Select
Femoral
Radial
Brachial
Axillary
Other
Side
*
Left
Right
Sheath/Device Size (Fr)
*
Access Technique
*
Please Select
Ultrasound-guided
Fluoroscopy-guided
Anatomic landmark
Other
Closure Method
*
Please Select
Manual Compression
Closure Device
Suture
Other
Complications
*
None
Bleeding/Hematoma
Pseudoaneurysm
Arterial Dissection
Other
Operator Name
*
Submit Record
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