1.6 Documentation for IV Initiation

Documentation Cues:

Accurate and complete documentation regarding IV initiation should include the following:

• Date/Time of procedure
• Manufacturer’s brand name of device
• Gauge and length of device
• Location of the accessed vein
• Use of local anesthetic
• Number of attempts for a successful IV start
• Description of the insertion site, such as “cephalic vein on dorsal surface of right lower arm, 2.5 cm (1 inch) above the wrist”
• Condition of extremity and IV site
• Type of dressing with which the cannula was secured
• Patient’s tolerance of the procedure and patient education provided
• If saline lock was established or if fluid was infused after IV initiation. If fluid was infused, the method of infusion (gravity or infusion pump), type and rate of infusion should be included.
• Patient’s status and integrity and patency of the system according to agency policy

Sample Documentation:

12/7/20XX 0845

Obtained peripheral IV access as ordered by provider. A suitable vein was identified in the patient’s right hand, and the site was cleansed with chlorhexidine per protocol. A 20-gauge 1-inch Protect IV was placed in the patient’s right hand. The vein was cannulated with one attempt, and no complications were noted during cannulation. The catheter was freely threaded into the vein after blood return was noted, and the site was flushed with normal saline and clamped. The site was dressed with a sterile tegaderm dressing and extension set tubing was secured. Following application of the dressing, the site was saline locked. The patient tolerated the procedure well with no signs of redness, swelling, or other complications.

Janika Smith, RN