Intravenous (IV) insertion charting is the documentation of placing a catheter into a patient’s vein. This record-keeping establishes a clear legal record of the medical intervention and supports patient safety by facilitating the early detection of complications, such as phlebitis or infiltration, which can be tracked over time. Charting ensures the continuity of care, allowing different healthcare providers to understand the history and status of the patient’s vascular access device.
Essential Elements of Initial Documentation
Initial documentation begins immediately upon successful placement, focusing on the objective facts of the insertion. Recording the exact date and time of the venipuncture provides a reference point for calculating the device’s maximum dwell time and monitoring schedule. The anatomical location of the catheter must be precisely identified, such as “Left forearm, cephalic vein,” to ensure accurate site assessment.
The physical specifications of the catheter must be recorded, including the gauge (diameter) and the length used. Documentation must also include the number of insertion attempts made before successful placement, along with the name or initials of the healthcare professional who performed the insertion.
Recording the Procedure and Immediate Patient Response
After initial facts are documented, charting shifts to the procedure and the patient’s immediate response. The type of antiseptic skin preparation used, such as chlorhexidine gluconate (CHG) or povidone-iodine, must be noted as an infection control measure. A description of the sterile dressing applied to secure the site should also be included.
Confirmation of the catheter’s functionality is documented by successful flushing, demonstrating the device is patent and ready for use. This involves noting that the line flushed easily with a sterile solution, like normal saline, without resistance or patient discomfort. The final step is documenting the patient’s immediate tolerance, noting any adverse event or pain rating.
Monitoring and Removal Documentation
Documentation continues throughout the life of the IV access, starting with regular site assessments to ensure the device remains safe. The frequency of these assessments (e.g., once per shift) must be recorded alongside the findings. Descriptions should be objective, noting if the site is clean, dry, and intact, or if there is redness or swelling.
Any maintenance procedures, such as a dressing change, require separate documentation of the date and time. When the IV access is discontinued, the removal process must be fully charted. Removal documentation includes the date and time the catheter was discontinued and a description of the insertion site post-removal. The integrity of the catheter tip must be confirmed and documented as intact to ensure no portion was retained within the vein.