PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH
Forms Used in IV Therapy
1. IV Fluid Sheet 2. Medication and Treatment Sheet 3. Blood Transfusion Sheet 4. Flowcharts 5. Endorsement Sheets
PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH
WHAT TO DOCUMENT A. During Initiation of IV Therapy 1. Size, length and type of device 2. Name of person inserting the device 3. Date and time 4. Site location 5. Type of solution and any additives added 6. Flow rate PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH 7. Use of an electronic infusion device of other type of flow controller 8. Complications 9. Patient response 10. Nursing Interventions 11. Patient teachings, evidence of patient understanding
PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH
B. During Maintenance of IV Therapy 1. Condition of the site 2. Site care provided 3. Dressings changes 4. Tubing and solution changes 5. Teaching and evidence of patient understanding.
PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH
C. During termination of IV Therapy 1. Date and time 2. Reason for discontinuing therapy 3. Assessment of the site before and after venous access device is removed. 4. Complications 5. Patient reactions 6. Nursing Interventions 7. Integrity of the venous device on removal 8. Follow-up PHILIPPINE actions. HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH DOCUMENTATION DO'S AND DON'TS 1. Do document what you observed first hand, what the patient said and what was done - not your opinions.
Don't write: Patient tolerated procedure well.
Instead write: That was painful but I'm relieved now
PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH
DOCUMENTATION DO'S AND DON'TS 2. Do write No IV-related complications observed to document your assessment of a complication-free venous access site. If you include specific observations such as no redness or swelling and not others, you could be accused of skipping some assessments.
PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH
DOCUMENTATION DO'S AND DON'TS 3. Do give details about complications. Document nursing interventions, physicians orders, patient comments regarding complication, and the patient's response to treatment.
PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH
DOCUMENTATION DO'S AND DON'TS 4. Don't write catheter tip intact when you remove a peripheral venous access device. Unless you examine it under a microscope, you can't legitimately make this statement.
PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH
DOCUMENTATION DO'S AND DON'TS 5. Don't rely sole on charting by exception or check-off flow sheets to document. They don't prove proper patient assessment and may not hold up in court.
PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH
DOCUMENTATION DO'S AND DON'TS 6. Definitely document any deviations from policy and the reasons for same, since hospital policy will be used as standard to benchmark your care.
Example: Extending the duration of a well-
running and patent IV line because the patient has an exhausted venous system.
PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH
Chatterjee, A., & Coslett, H.B. (Eds.) (2014) - The Roots of Cognitive Neuroscience. Behavioral Neurology and Neuropsychology. Oxford University Press PDF