Central Venous Access Device Assessment Note (Pediatric Oncology)

Date/Time: [Date and time of assessment]

Location: [clinic / infusion center / inpatient / ED]

Provider: [Provider name and credentials]

Service: [Service/team]

Reason for Assessment

[REQUIRED: Reason for assessment—routine maintenance, dressing issue, flush difficulty, fever/infection concern, swelling/thrombosis concern, device damage, or other indication]

Device Identification

• Device type: [implanted port / PICC / tunneled CVL / non-tunneled CVC] (State explicitly; do not infer.)
• Location: [Side and anatomic site] (If unable to verify: "Unknown—sources checked: [sources]")
• Lumens: [single / double / triple; lumen labels if applicable]
• Access status: [accessed with noncoring needle / deaccessed / N/A]
• Key dates: [Insertion date, last dressing change, last needle change if port—include when available]

Subjective

[Line-related interval history: fever/chills, site symptoms, flush difficulty or occlusion alarms, limb/neck/face swelling, recent access frequency] (Use direct patient/caregiver quotes for key complaints. Document "not assessed" rather than inferring negatives for symptoms not asked about.)

Objective

• Vitals: [Temperature and other vitals as relevant] (Include only if obtained today.)
• Site/Dressing: [Visualization status; skin integrity; erythema with size if present; tenderness; drainage; dressing type and integrity; securement status; for ports: pocket palpation findings] (Distinguish what was directly visualized versus assessed through dressing.)
• Function: (Document per lumen. Never document blood return as present unless verified.)
  • Lumen [label]: [flush: easy / resistance / unable] [blood return: brisk / sluggish / none / positional / not assessed] [infusion: able / unable] [pain with flush: yes / no / not assessed]
  • (Repeat for each lumen as applicable.)
• Troubleshooting: [Positional maneuvers, connector/needle/dressing change, thrombolytic agent/dose/dwell/outcome—with response to each intervention] (Omit if none performed.)
• Diagnostics: [Cultures: peripheral vs catheter, specific lumen(s), obtained before antibiotics yes/no; imaging for malposition or thrombosis] (Omit if none obtained/ordered.)

Assessment

(Number problems from most urgent to least. Use "concern for" or "findings consistent with" language; avoid definitive diagnostic terms without confirmatory data.)

• Problem 1: [Clinical concern—e.g., suspected catheter-related infection, CVAD dysfunction/occlusion, suspected catheter-associated thrombosis, dressing/skin integrity issue, device damage]
  [Brief supporting findings]
• (Add additional problems as applicable.)

Plan

(Address each assessment problem. Omit items not applicable to this encounter.)

• Problem 1:
  • [Actions taken today]
  • [Orders placed: cultures, imaging, antibiotics, consults]
  • [Line management decision: retain / remove / exchange / observe with rationale if discussed]
  • [Monitoring instructions and return precautions]
  • [Follow-up interval and responsible party]
• (Repeat for each additional problem.)
• [For routine assessment with normal findings: "CVAD appropriate for continued use" with next maintenance due date] (Include only if all elements verified.)