Documentation
Documentation
Policy
Documentation regarding the patient’s infusion therapy and vascular access will contain accurate, factual, and complete information in the patient’s permanent medical record.
Documentation is to be legible, timely, accessible to qualified personnel, and readily retrievable.
The forms, methods of documentation, storage, and retention requirements of the patient’s permanent medical record, with attention to the federal regulations of the Health Insurance Portability and Accountability Act (HIPAA), are determined by the organization.
Procedure
Documentation should include, but is not limited to, the following:
General
Pertinent nursing diagnosis (problem)
Initial and ongoing assessment and appropriate vital signs
Patient’s response to device insertion and therapy, including symptoms, side effects, or complications
Laboratory test results as appropriate
Patient and/or caregiver education
In relation to the vascular access device (VAD) and/or the infusion therapy
Evaluation of understanding
Barriers to patient education
VAD placement
Site preparation, infection prevention, and safety precautions taken during VAD placement; completion of a standardized tool for documenting adherence to recommended practices
Type, length, and gauge/size of VAD inserted
For central vascular access devices (CVADs) and all long-term infusion devices, the manufacturer and lot number
Date and time of insertion, number and location of attempts, functionality of device
Local anesthetic, if used
Insertion methodology, including visualization and guidance technologies
Identification of the insertion site by anatomical descriptors, laterality, landmarks, or appropriately marked drawings
For midline (ML) and peripherally inserted central catheters (PICCs): external catheter length, baseline mid-upper extremity circumference, and effective length of catheter inserted
Radiographic confirmation of the anatomic location of the catheter tip location for all CVADs prior to initial use
VAD ongoing assessment and monitoring
Condition of the site, dressing, type of catheter stabilization, dressing change, site care, patient report of discomfort, pain, any changes related to the site
A standardized assessment, appropriate for patient populations, for phlebitis, infiltration, or extravasation, allowing for accurate and reliable assessment on initial identification and with each subsequent site assessment
Daily assessment of the need for continuation of the VAD
Radiographic confirmation of the anatomic location of the catheter tip location for all CVADs for any apparent dysfunction of the catheter
Upon removal: condition of site, condition of the catheter and length, reason for device removal, nursing interventions during removal, dressing applied, patient response, date/time of removal
If cultures obtained: source of culture (eg, site, device, or blood)
Infusion therapy administration
Type of therapy, drug, dose, rate, time, route, and method of administration
When multiple VADs or catheter lumens are used, indication of what fluids and medications are being infused through each pathway
Bibliography
American Nurses Association. Nursing: Scope and Standards of Practice. 2nd ed. Silver Spring, MD: ANA; 2010.
Dugger B. Documentation. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing: An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:540-549.
Hagle M, Johnson B, Ladewig N, Montenero D, Pawlak T. Central venous access. In: Weinstein S, ed. Plumer’s Principles & Practice of Intravenous Therapy. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:277-330.
Maxwell B. Documentation and informatics. In: Potter P, Perry A, eds. Fundamentals of Nursing. 7th ed. St. Louis, MO: Mosby/Elsevier; 2009:384-409.
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