Blood Gas Sampling Procedure Note (Arterial/Capillary)

Date/Time Authored: [Date and time note authored]  |  Date/Time Specimen Obtained: [Date and time specimen collected]

Location: [Unit / Room / Bed]  |  Operator: [Name, credentials]  |  Patient: [Per institutional policy]

Procedure Summary

[1–3 sentence summary including: sampling source and type (percutaneous arterial puncture / arterial line draw / arterialized capillary sampling); site and laterality; number of attempts; pain mitigation used or reason not used; complications or "none"; handling statement (e.g., "analyzed within X minutes"); and respiratory support status at time of draw (device + FiO₂ or flow rate + SpO₂)] (All listed elements are required. Use [Not documented] for any element not available from the encounter.)

Indication

[Clinical indication for blood gas] (Examples: assess ventilation/acid-base status, assess oxygenation or response to oxygen therapy, evaluate response to ventilator change, suspected hypercapnia, worsening respiratory status, metabolic acidosis/alkalosis evaluation. If unclear from order but supported by encounter, use "obtained due to clinical deterioration." Do not infer indication.)

Clinical Status at Time of Draw

• SpO₂: [Value %]
• Respiratory Support: [Room air / Nasal cannula / Simple mask / Venturi mask / Non-rebreather / HFNC / CPAP / BiPAP / Mechanical ventilator / Other]
  • (If nasal cannula: document flow rate in L/min; do not convert to estimated FiO₂ unless labeled as estimate.)
  • (If HFNC: document flow rate in L/min and FiO₂.)
  • (If CPAP/BiPAP: document mode, EPAP/PEEP, IPAP or PS, backup RR if applicable, and FiO₂.)
  • (If mechanical ventilator: document mode, set RR if applicable, Vt or Pinsp, PEEP, PS if applicable, and FiO₂.)
• Time Since Last O₂/Vent Change: [Minutes since change and what changed / No recent changes] (Note if patient not at steady state.)
• [HR, RR, BP, temperature, perfusion status at sampling site] (Optional; include only if documented. Perfusion status especially relevant for capillary sampling.)

Pre-Procedure

• Patient ID & Order Verification: [Two identifiers confirmed; order verified]
• Contraindications Screened: [Anticoagulation/coagulopathy status; site infection or skin compromise; AV fistula presence; limb perfusion] (For arterial puncture: document collateral circulation assessment with method and result, or state "not performed per policy.")
• Pain Mitigation: [Local anesthetic agent, dose, timing / Comfort measures used (e.g., oral sucrose, swaddling, warming) / Reason not used: emergent / patient declined / contraindication] (Required for arterial puncture. For neonatal/infant capillary sampling, document comfort measures if applicable.)
• Aseptic Technique: [Hand hygiene performed; gloves worn; skin antisepsis applied and allowed to dry; safety-engineered device used; sharps disposed immediately without recapping]
• [Time-out completed per institutional policy] (Include only if performed.)

Sampling Procedure

(Include only the subsection corresponding to the sampling source used. Omit non-applicable subsections entirely.)

Percutaneous Arterial Puncture

• Site & Laterality: [Radial / Brachial / Femoral / Dorsalis pedis / Other] [Right / Left] (If non-radial site, include brief rationale.)
• Positioning: [Patient and limb positioning]
• Needle & Device: [Gauge] needle; [pre-heparinized syringe type]
• Attempts: [Number of attempts] (If multiple, note sequence and sites.)
• Arterial Appearance: [Pulsatile flow, bright red consistent with arterial / Uncertain]
• Hemostasis: [Method and duration of pressure applied]
• Post-Procedure Check: [Bleeding controlled; distal perfusion intact]
• Dressing: [Dressing type applied]

Arterial Line Draw

• Line Location: [Site and laterality]; Patency/Waveform: [Good / Damped / Lost]
• Dilution Avoidance: [Waste volume drawn and discarded / Return method per unit protocol]
• Complications During Draw: [None / Hub bleeding / Waveform loss / Other]

Capillary Sampling

• Site & Laterality: [Heel posterolateral / Finger / Earlobe / Other] [Right / Left]
• Perfusion at Site: [Adequate / Poor]
• Arterialization: [Warming method/device; duration; burn precautions observed]
• Lancet & Punctures: [Lancet type]; [number of punctures]
• Collection Device: [Heparinized capillary tube type]
• Hemostasis & Dressing: [Method; dressing applied]

Specimen Handling

• Time Specimen Obtained: [HH:MM]
• Container: [Pre-heparinized syringe / Heparinized capillary tube]
• Air Bubbles: [Absent / Present and expelled / Present, not expelled]
• Mixing: [Gently rolled/inverted to distribute anticoagulant]
• Labeling: [Labeled at bedside with patient identifiers and draw time]
• Transport: [Hand-carried / Pneumatic tube]; [Room temperature / Chilled] (If chilled, include rationale.)
• Time Analyzed/Received: [HH:MM]
• Draw-to-Analysis Time: [Total minutes]
• [Delay reason and actions taken] (Include only if delay occurred.)
• [Specimen rejected/clotted/insufficient: disposition and whether recollection performed] (Include only if applicable.)

Complications & Patient Tolerance

• Patient Tolerance: [Well tolerated / Mild distress / Significant distress]; [Pain score if obtained]
• Complications: [None / Hematoma / Prolonged bleeding / Vasovagal episode / Arterial spasm / Paresthesia / Ischemic signs / Other] (Must document explicitly, including "None" if no complications.)
• Interventions: [Extended pressure / Ice or elevation / Analgesia / Provider notified / Escalation of care / Other actions taken] (Include only if complications occurred.)
• [Extended pressure duration and reassessment plan for anticoagulated or high-risk patients] (Include if applicable.)

Follow-Up Plan

[Repeat blood gas timing if indicated; consideration of arterial line if repeated sampling anticipated; site monitoring instructions] (Omit section if no follow-up actions required.)

Signature

Electronic Signature: [Operator name, credentials, date/time]