Central Line Maintenance Note (Dressing Change/Line Assessment)

Date/Time of Note: [Date and time]

Date/Time of Procedure: [Date and time] (Include only if different from note time.)

Clinician: [Name], [Credentials], [Role]

Current Lines: [Number] central line(s); [Number] peripheral IV(s)

Device Identification

(Create a separate Device Identification subsection for each central line addressed in this note.)

• Device type: [Non-tunneled CVC / PICC / Tunneled CVC / Implanted port / Hemodialysis catheter / Other]
• Laterality and anatomic site: [Laterality and site, e.g., Right IJ, Left basilic]
• Number of lumens: [Single / Double / Triple / Quad / Other]
• External catheter length or cm marking at skin: [Numeric value with unit / Unable to verify (state where verification attempted: bandage label, line card, EHR)]
• Securement method: [Sutures / Sutureless device / Integrated / Other]
• Insertion date: [Date / Unable to verify (state where verification attempted)]

Indication

• [Scheduled dressing change due / Dressing compromised (damp/loose/soiled) / Scheduled connector/cap change due / Line assessment only (no change performed) / Site symptoms (pain/tenderness) / Concern for infection / Concern for occlusion/poor blood return / Concern for dislodgement/migration/leak / Post-procedure reassessment / Other]

[Brief non-routine context] (Include only for non-routine situations requiring additional explanation.)

Site Assessment

(Document explicit findings for each element. For safety-critical fields, if unable to observe, select "unable to assess" with reason rather than omitting.)

• Erythema: [None / Mild / Moderate / Severe / Unable to assess (reason)] [Size in cm if present]
• Edema/swelling: [None / Present / Unable to assess (reason)]
• Drainage: [None / Serous / Bloody / Purulent / Unable to assess (reason)] [Amount if present]
• Tenderness: [None / Mild / Moderate / Severe / Unable to assess (reason)]
• Skin integrity: [Intact / Maceration / Skin tear / Blistering / Contact dermatitis / Unable to assess (reason)]

Dressing Status

• Current dressing type: [Transparent / Gauze / Antimicrobial/CHG-containing / Other]
• Integrity: [Clean/dry/intact/occlusive / Compromised (damp/loose/soiled/lifting edges)]
• Blood/fluid under dressing: [Yes / No]
• Date label present and legible: [Yes / No]

Catheter Position

• External length compared to baseline: [Unchanged / Increased / Decreased / Unable to assess (reason)]
• Securement intact and no tension: [Yes / No]

Lumen Assessment

(Create a subsection for each lumen. If lumen not clinically assessed, state "not assessed" with reason.)

Lumen [Number/Label]

• Current use: [Infusing / Locked / Saline lock / TPN / Blood products / Other]
• Blood return: [Present / Absent (reason) / Unable to assess (reason)]
• Flush: [Easy / Resistance (describe) / Not performed (reason)]
• Complications: [None / Pain / Swelling / Leakage]

Interventions Performed

(Include only subsections for interventions actually performed. Omit subsections entirely if intervention not performed.)

Dressing Changed

• Indication: [Scheduled / Compromised / Bleeding/oozing / Other]
• Skin condition after old dressing removal: [Description of site condition including erythema, drainage, skin integrity]
• Antiseptic used: [CHG with alcohol / CHG aqueous / Povidone-iodine / Alcohol / Other] (If not CHG, document reason.)
• Friction/scrub performed and antiseptic allowed to dry: [Yes / No (explain)]
• New dressing type applied: [Transparent / Gauze / Antimicrobial/CHG-containing / Other]
• CHG/antimicrobial dressing component used: [Yes / No / NA]
• Dressing labeled with date/time/initials: [Yes / No]
• Patient tolerance: [Tolerated well / Discomfort (describe) / Other]

Connector/Cap Changed

• Lumen(s): [List lumen numbers/labels]
• Indication: [Scheduled / Contamination concern / After blood draw / Other]
• Hub disinfected with friction before access: [Yes / No] (Agent: [Alcohol / CHG / Other])
• Antiseptic barrier cap applied after change: [Yes / No / NA]
• Patency confirmed post-change: [Yes / No (explain)]

Tubing Changed

• Sets and lumens: [Primary / Secondary / Extension] on [Lumen(s)]
• Indication: [Scheduled / Contamination / Medication-specific interval]
• Infusate type: [Crystalloid / Blood products / Lipids/TPN / Other]
• Tubing labeled: [Yes / No]

Flush/Lock Performed

• Per lumen solution and volume: [List each lumen with solution type and volume]
• Resistance encountered: [No / Yes (flushing not forced; escalated per protocol)]

Bundle Compliance

(Active attestation required. If any element not performed, provide brief explanation.)

• Hand hygiene performed: [Yes / No (explain)]
• Aseptic technique maintained: [Yes / No (explain)]
• Hub disinfected before any access: [Yes / No (explain) / NA]
• Line necessity reviewed today: [Yes / No / Unknown]
• Daily CHG bathing performed/ordered: [Yes / No / NA / Contraindicated] (ICU settings)

Concerns and Escalation

(Include this section only when abnormal findings or concerns exist. Document recognition, actions, and communication.)

Infection Concern

• Findings prompting concern: [Erythema / Purulence / Tenderness / Fever / Chills / Hypotension]
• Provider notified: [Name], [Time]
• Blood cultures ordered/obtained: [Yes / No] (If yes — Draw sites: [Peripheral / Lumen (specify)]; Specimens labeled by site: [Yes / No])
• Site culture if drainage present: [Yes / No / NA]
• Line removal: [Considered / Performed / Not indicated at this time]
• Plan for line use pending evaluation: [Continue use / Restrict use / Hold use / Other]

Occlusion/Poor Blood Return

• Lumen(s) affected: [List]
• Severity: [Sluggish flush / No flush / No blood return only]
• Troubleshooting performed: [Repositioning / Arm raise / Cough / Warm compress / Other]
• Thrombolytic: [Considered / Administered per protocol / Not indicated]
• Provider/vascular access team notified: [Name], [Time]

Dislodgement/Migration/Leak

• External length change or visible migration: [Change in cm / Visible migration / None]
• Leak location: [Site / Hub / Tubing / NA]
• Immediate actions: [Stopped infusion / Clamped / Covered site / Other]
• Escalation and plan: [Provider/team notified with name, time, and next steps]

Post-Procedure Check

(Include when any intervention performed.)

• Dressing occlusive and intact: [Yes / No (describe)]
• No active bleeding: [Yes / No (describe)]
• Patient comfort acceptable: [Yes / No (describe)]
• Complications: [None / Bleeding / Skin tear / Contamination concern / Migration / Other (describe actions taken)]

Plan

[Brief summary of device status and interventions performed] (1–2 sentences.)

• Next dressing change due: [Date/time]
• Next connector/cap change due: [Date/time]
• Next tubing change due: [Date/time / NA]
• Follow-up needed: [Vascular access consult / Provider reassessment / Culture results review / None / Other]