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Discussion

Documenting an IV insertion?

Can anyone give an example of a documentation of an IV insertion? Thank you.

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    • Solved by iluvivt

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    I always write: 16g A/C PIV placed x1 attempt. Flushes easily and with no c/o discomfort from pt. positive blood return. tegaderm applied....

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    emtrachel said:
    Does anyone ever document "using aseptic technique" or it this just a given? When writing reports for EMS, this is something we document.

    The further I'm getting in my nursing courses, the more differences I'm finding between the 2 fields...

    I've never seen anyone chart that. I would think that it is a given in a hospital situation, except maybe in a trauma, but even then the ones I've seen have all been under aseptic conditions. I think this may be unique to EMS...a lot of facilities have P&P to restart a line placed in the field after 24hrs. or less due to field lines being possibly "contaminated" assuming EMS may not have the time or supplies readily available under certain circumstances when doing an IV start.

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    • Experts

    From these guidelines a charting template can be put together for your own use that incorporates your writing style to refer to when charting each IV access.

    This is the INS Standard (2006 Infusion Nursing Standards of Practice?

    • "Standard 14.1 - Nursing documentation shall contain complete information regarding infusion therapy and vascular access in the patient's permanent medical record.
      • Practice Criteria B - Documentation should include, but not be limited to, the following
        • 2. Type, brand, length, and size of vascular device.
        • 3. Date and time of insertion, number and location of attempts, type of catheter stabilization and dressing, patient's response to the insertion, and identification of the person inserting the device.
        • 4. Use of visualization and guidance technologies.
        • 5. Identification of insertion site by anatomical descriptors, landmarks, or appropriately marked drawings.
        • 10. Specific site preparation, infection control, and safety precautions taken.
        • 11. Communication among the healthcare team members responsible for patient care and monitoring,
        • 17. ....indicate what fluids and medications are being infused...."
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