IV Therapy/PICC-Midline Care Procedure Note

Date/Time of Service: [date and time of encounter] (If late entry, include date/time of documentation and date/time event occurred.)

Location/Setting: [inpatient unit / infusion center / home visit / clinic / other]

Author Name and Credentials: [full name, credentials, role]

Indication for Encounter: [routine scheduled maintenance / soiled or loose dressing / concern for infection / occlusion / therapy initiation / other]

Device Identification

• Device Category: [PICC / Midline / other]
• Laterality and Insertion Site: [right / left], [vein: basilic / brachial / cephalic / other / unknown]
• Device Characteristics: [French size], [number of lumens], [valved / non-valved], [power-injectable: yes / no / unknown]
• Insertion Date: [date / unable to verify]
• Last Dressing Change: [date / unable to verify]
• Last Cap/Connector Change: [date / unable to verify]
• External Catheter Length Today: [length in cm]
• Last Documented External Length: [length in cm / unknown]
• Variance From Prior: [variance in cm] (If variance exceeds policy threshold, address in Complications and Corrective Actions.)
• Securement Method Present: [sutureless device / integrated securement dressing / sutures / adhesive anchor / none / other]

Assessment

Patient Status

• Pain at/near Site: [0-10 score], [location], [character if provided]
• Systemic Symptoms Reported: [fever / chills / none / other]
• Tolerance/Cooperation: [tolerated well / anxious / limited cooperation / other]

Site and Limb Assessment

• Dressing Condition: [clean / dry / intact / occlusive / soiled / damp / loose / edges lifting], [date visible: yes / no]
• Skin and Exit Site: [erythema / warmth / tenderness / swelling / drainage / bleeding / rash / none] (Only document elements personally assessed.)
• Limb Findings: [edema / pain along vein / cording / discoloration / none]
• Catheter Integrity: [no kinks, cracks, or leaks observed / kinks / cracks / leaks / migration concern] (If migration concern, correlate with external length variance.)

Line Function

(Document per lumen. Do not summarize as "all patent" unless each lumen individually assessed.)

• Lumen: [color/name/number]
• Flush Response: [easy / slight resistance / significant resistance / unable to flush]
• Blood Return: [present / absent / not assessed] (If absent, document troubleshooting and outcome.)
• Patient Symptoms During Flush: [none / pain / burning / swelling / other]
• Cap/Connector Status: [intact / discolored / blood in hub / leaking / loose / other]

Aseptic Technique and Supplies

(Include only when dressing change, cap/connector change, or line access occurred.)

• Hand Hygiene: [performed before and after per protocol]
• PPE Used: [mask / clean gloves / sterile gloves / eye protection], [patient masked: yes / no]
• Sterile Field: [established and maintained / compromised]
• Scrub-the-Hub: [agent], [contact time], [friction applied: yes / no]
• Skin Antisepsis: [agent: 2% CHG in alcohol / povidone-iodine / alcohol / other], [allowed to dry fully before dressing: yes / no]
• Supplies Utilized: [dressing type, securement device, connectors, flushes, locks]

Procedure Performed

(Document only procedures performed; omit subsections that do not apply.)

Dressing Change

• Indication: [routine / compromised / bleeding / suspected infection / other]
• Removal and Inspection: [dressing removed; site inspected; skin findings]
• External Length Measurements: [pre-change cm], [post-change cm]
• Dressing Applied: [transparent semipermeable / gauze / bordered / CHG-impregnated / other]
• Securement: [device changed / device applied / existing maintained]
• Labeling: [dressing labeled with date/time/initials: yes / no]
• Patient Tolerance: [tolerated well / discomfort / analgesia required]

Cap/Connector Change

• Lumens Changed: [list lumens]
• Disinfection Before Removal: [agent and contact time]
• New Connector Type: [neutral / anti-reflux / positive displacement / other], [dated: yes / no]
• Observations: [blood reflux / clotting observed / none]

Flushing/Locking

(Document per lumen.)

• Lumen: [color/name/number]
• Flush Solution/Volume: [solution and volume]
• Technique: [pulsatile / continuous], [positive-pressure clamp: yes / no]
• Lock Solution: [none / heparin / citrate / other with concentration and volume]
• Response: [no resistance / resistance / pain / swelling / leakage / other]

Blood Draw

(Include only if performed.)

• Lumen Used: [color/name/number]
• Waste Volume: [volume in mL]
• Sample Obtained: [yes / no]
• Post-Draw Flush: [solution and volume]

Infusion Initiation/Management

(Include only if applicable; reference MAR for dosing details.)

• Therapy Infused: [medication/solution name]
• Route and Lumen Used: [device type; lumen identifier]
• Rate/Method: [rate], [pump / gravity]
• Start Time: [time] Stop Time: [time / ongoing]
• Compatibility Checks: [performed; incompatibilities addressed]
• Monitoring During Infusion: [site checks and findings], [patient symptoms]

Complications and Corrective Actions

[Complications: None observed; patient tolerated procedure well.]

(If complications occurred, use problem-oriented format below. Repeat per issue.)

• Issue: [mechanical / functional / site / infection concern / extravasation], [time observed]
• Objective Findings: [what was observed/measured]
• Actions Attempted: [troubleshooting steps with responses]
• Actions Not Attempted and Why: [reason if applicable]
• Escalation: [who notified, when, orders received]
• Disposition/Plan: [monitoring, imaging, cultures, declot attempt, line salvage vs removal, follow-up]

Patient Education

• Topics Covered: [keeping dressing clean/dry; shower protection; when to seek care; activity precautions; home flush schedule if applicable]
• Method: [verbal / written handout / demonstration]
• Teach-Back: [performed; response: accurate / partial / unable]
• Barriers: [none / interpreter used / cognitive / hearing / vision / declined teaching]

Follow-Up Plan

• Next Dressing Change Due: [date per dressing type and policy]
• Next Cap/Connector Change Due: [date per policy]
• Flush Schedule: [solution, volume, frequency per lumen] (Include for outpatients.)
• Monitoring Plan: [triggers for re-evaluation; site check frequency]
• Escalation Thresholds: [fever without source; purulent drainage; new arm/neck/chest swelling; catheter damage; inability to flush; suspected migration/extravasation]
• Disposition/Handoff: [care transferred to; report given to] (Include if applicable.)

Signature

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

Co-Signature: [co-signer name, credentials, date/time] (Include only if required by organizational policy.)