IV Hydration/Infusion Therapy Procedure Note

(If this is a late entry, begin with "Late Entry" and include the current date/time and rationale for late documentation.)

Date: [Encounter date]

Patient: [Full name] | [DOB] | [MRN]

Location: [Clinic/site]

Ordering Clinician: [Name, credentials]

Documenting Clinician: [Name, credentials, role]

Indication / Diagnosis

[Primary indication/diagnosis with clinical context supporting medical necessity]

(Describe current symptoms/signs and relevant findings prompting therapy; include functional impact when stated. Note comorbidities that influence risk or monitoring requirements. Do not infer indication from the medication order alone.)

Pre-Infusion Assessment

• Allergies and prior infusion/injection reactions: [Allergy list with reactions; history of infusion/injection reactions]
• Baseline vitals: [BP] | [HR] | [RR] | [SpO2] | [Temperature]
• Weight: [Weight and date] (Include if dosing is weight-based or volume tolerance is a concern. If required by protocol but unavailable, document unavailability and prescriber notification.)
• Focused symptom assessment: [Pertinent symptoms/findings related to indication]
• Vascular access assessment: [Vein quality] | [Limb restrictions] | [Skin/site condition] | [Edema or contraindications]
• Pertinent labs: [Required labs and results with dates] (If protocol-required labs are unavailable, document absence and prescriber notification.)
• Consent: [verbal / written / general consent on file] | [Date/time]
• Patient education provided: [Key teaching points, including symptoms to report immediately]

IV Access

• Device Type: [peripheral IV / midline / PICC / port / other]
• Site: [Laterality] | [Anatomic location]
• Gauge/Size: [Catheter gauge and length] (For pre-existing access, document "unknown" if not available.)
• Attempts: [Number of attempts] by [Inserter name, credentials]
• Technique: [Skin antisepsis agent] | Aseptic technique confirmed (Note ultrasound or vein finder use if applicable.)
• Patency: [Blood return present / flush without resistance / other verification method]
• Securement: [Dressing type] | [Site condition]
• Central access (if applicable): [Line function assessment] | [Access method and needle size for port] | [Cap/tubing changes per protocol]

Therapy Administered

(Repeat for each administered substance. Document actual administration times, not ordered times. If a prepared bag was not administered, note this with reason and disposition.)

Administered Substance [#]

• Substance: [Name (e.g., 0.9% NS, LR, medication name)]
• Purpose: [hydration / therapeutic medication / flush]
• Dose/Volume: [Concentration and dose for medications; total volume for fluids]
• Route/Method: [IV infusion / IV push]
• Rate: [Ordered rate] | [Actual rate] | [pump / gravity] | [Titration parameters if used]
• Start Time: [HH:MM]
• Stop Time: [HH:MM] (Or total infusion duration.)
• Interruptions: [Pause time(s), restart time(s), and reason] (If none, state "None.")

Monitoring / Reassessment

(If detailed monitoring is captured in a flowsheet, reference it and summarize clinically significant events here.)

• Vital signs: [Baseline] | [Intra-infusion with times, if indicated] | [Post-infusion, if indicated]
• Infusion site checks: [Pain/swelling/erythema status; blood return verification]
• Symptom reassessment: [Changes in symptoms or functional status related to indication]
• Overall tolerance: [Well tolerated / mild issues / significant issues with details]

Adverse Events / Complications

[No adverse reactions or complications observed or reported.]

(If adverse events occurred, replace the above statement with the following details:)

• Event type and onset: [Type of reaction/complication] | [Date/time of onset]
• Signs/symptoms and vitals: [Clinical findings with times]
• Immediate actions: [Stopped infusion / position change / oxygen / other]
• Medications/interventions: [Name, dose, route, time] | [Response]
• Provider notifications: [Who notified and when]
• Disposition/follow-up: [Observation / transfer / discharge instructions; next steps]

Post-Infusion Status / Discharge

• End-of-infusion vitals: [Values] (Include when clinically indicated.)
• Response to therapy: [Clinical response and patient-reported outcomes]
• IV disposition: [Peripheral IV removed, catheter intact / left in place with reason] | [Site condition] | [Dressing applied]
• Central access: [Flushed/locked per protocol] | [Needle removed if port] | [Dressing status] (Include only if applicable.)
• Patient condition: [stable / improved / other] | [Readiness to leave confirmed]
• Return precautions provided: [Allergic reaction symptoms, IV site worsening, fever/chills, chest pain, shortness of breath]
• Follow-up plan: [Next infusion appointment if scheduled] | [Follow-up with ordering clinician/PCP]

Authentication

Author: [Name, credentials]

Signature Date/Time: [Date/time]