It’s an interesting question and more interesting is how different nurses describe their documentation of an IV start. A few nursing colleagues on IVchat said: (thanks, twitter buddies)
“created stamp for chart that identifies size, site, no. of attempts, time date and operator” (site meant 2 refer 2 the actual vein & location, if u know ur anatomy well enough. most just put back of hand, etc)
“since we are computerized, the form (text) actually has all that info when re start or restart.”
“We use anatomical description: “right hand, third metacarpal vein”
I have seen a few good documentation forms specific to IV access and I reviewed a few medical records where I couldn’t find any notation that an IV was even started yet is the source of litigation. Sometimes, the nurse states the patient’s peripheral IV is on the left when it is actually on the right because the patient is a left arm amputee. OY!
The recently revised Infusion Nursing Standards of Practice (2011) S14 Documentation states:
- Documentation should include, but not limited to: (excerpts)
- For all infusion devices, type, length, and gauge/size of vascular access device inserted.
- Date and time of insertion, number and location of attempt, functionality of device, local anesthetic (if used), and the insertion methodology, including visualization and guidance technologies.
- Identification of the insertion site by anatomical descriptors, laterality, landmarks, or appropriately marked drawings.
Organization’s policies and procedures dictate IV documentation guidelines, ideally should use sources such as the INS standards of practice, and other applicable practice guidelines, state and federal regulations. Sad to think there are many variations from one organization to another and even within an organization, where some nurses in patient care units are better in following their IV documentation guidelines, others are not, for whatever reason. Following an organization’s policies and procedures and INS Standards of Practice is just good practice and perhaps someday will be a good defense.
So, tell us how do you document your IV starts?
For more information or to purchase the 2011 Infusion Nursing Standards of Practice, click here.