Non-Tunneled Central Venous Catheter/Introducer Placement Procedure Note

Procedure: Non-Tunneled Central Venous Catheter and/or Introducer Placement

Date/Time: [Date and time of procedure]

Location: [ICU / ED / OR / bedside / other]

Urgency: [elective / urgent / emergent]

Patient Position: [Position] (Include only if clinically relevant, e.g., Trendelenburg for air embolism prevention.)

Procedure Summary

[Single-sentence summary including: side and site, device type(s) placed, guidance method, sterile technique, number of attempts, immediate complications or none, and tip confirmation status] (Construct as one concise sentence, e.g., "Right internal jugular triple-lumen CVC placed under real-time ultrasound guidance using maximal sterile barrier; single attempt; no immediate complications; tip position confirmed by CXR.")

Operators

Primary Operator: [Name, credentials]

Assistant(s): [Name(s) and role(s)] (Omit line if none.)

Indication

[Clinical indication(s) for central venous access] (List only operator-stated indications; do not infer from orders alone.)

Relevant Risk Factors

[Patient-specific factors that influenced planning or site selection] (Include only if such factors were present; omit section entirely if none. Examples: coagulopathy, known thrombosis, dialysis access considerations, local infection.)

Consent

• Consent obtained: [yes / no]
• Type: [written / verbal per facility policy]
• Obtained from: [patient / surrogate name and relationship]
• Risks discussed: [Risks reviewed with patient/surrogate]
• Alternatives and questions: [Alternatives discussed and questions answered]

(If emergency exception invoked, explicitly document why consent could not be obtained and the clinical necessity for proceeding.)

Time-Out

[Time-out attestation confirming correct patient, correct procedure, and correct site/side; allergies reviewed; equipment confirmed available] (If time-out not performed, explicitly document reason as this represents a safety deviation.)

Sterile Technique

(Do not assume compliance. Use "Not documented" if unknown. If suboptimal due to emergency, document deviation and plan for line replacement per policy.)

• Hand hygiene: [performed / Not documented]
• Maximal sterile barrier: [cap, mask, sterile gown, sterile gloves, full-body drape / Not documented]
• Skin antisepsis: [Agent used and adequate dry time allowed / Not documented]
• Sterile ultrasound cover: [used with sterile gel / Not documented] (Include only if ultrasound performed.)
• Deviations: [None / Deviation due to emergency; plan for line replacement per policy]

Anesthesia

• Local anesthetic: [Agent and volume]
• Sedation medications: [Name, dose, route] (Include only if proceduralist-administered.)

(Omit section if no anesthesia given or if sedation managed by anesthesia team.)

Site and Ultrasound

• Insertion site: [Right / Left] [internal jugular / subclavian / axillary / femoral / external jugular]
• Ultrasound: [Real-time guidance / Static pre-procedure scan / No ultrasound used]
• Vessel patency: [Assessed and patent / Not assessed] (If ultrasound used.)
• Images saved: [yes / no / Not documented] (Required if claiming ultrasound guidance for billing.)
• Limitations: [None / Limitations encountered]
• Additional sites attempted: [Site, side, and reason for switching] (Omit if single site.)

Procedure Details

• Technique: [Seldinger / micropuncture / catheter-over-needle]
• Number of attempts: [Number / not recorded] (Defined as needle passes at skin level; do not reconstruct from memory.)
• Venous access confirmation prior to dilation: [Confirmation method] (Blood color/non-pulsatility alone is not definitive.)
• Guidewire: [Removed and intact / Not documented]
• Catheter depth: [cm at skin]
• Lumen check: [Blood return and flush confirmed from all ports / Issue noted]
• Estimated blood loss: [Amount]

Device

(Complete applicable subsection(s); omit devices not placed.)

Central Venous Catheter

• Type: [single / double / triple / quad] lumen
• Size: [French gauge] Fr, [length] cm
• Brand/lot: [Brand and lot number] (If required by institutional tracking.)

Introducer

• Size: [French gauge] Fr, [length] cm
• Side port: [Aspirated and flushed, function verified / Not documented]
• Valve integrity: [Checked / Not documented]

(If catheter placed through introducer, document that device separately.)

Securement and Dressing

• Securement: [sutures / sutureless device / both]
• Dressing: [Dressing type applied]
• Line labeled: [yes / no]

Complications

[No immediate complications observed. / Complication(s) with supporting evidence, immediate management, and current status] (If patient transferred before reassessment: note reassessment not performed due to transfer. For arterial cannulation with ≥6 Fr device, document whether device left in place and specialty consultation obtained.)

Tip Position Confirmation

• Confirmation method: [CXR / fluoroscopy / ECG-based / point-of-care ultrasound / pressure waveform / other]
• Result: [Acceptable tip position confirmed with location / Pending with expected timing / Malposition identified with plan]
• Pneumothorax assessment: [Method and result] (For IJ/subclavian sites.)
• Line ready for use: [Yes, confirmation requirements met / No, pending requirements and use restrictions / Emergency use authorized with justification]

(Do not infer usability from blood return alone; explicitly document confirmation status.)

Post-Procedure

• Patient tolerance: [well tolerated / significant discomfort / other]
• Hemodynamic/respiratory status: [Brief assessment]
• Plan: [Pending orders, maintenance care, or replacement plan if applicable]

Attestation

Operator signature: [Name, credentials]

(For required elements—sterile technique, ultrasound use, attempt count, tip confirmation—use "Not documented" if unknown rather than omitting. Omit conditional sections entirely when not applicable. Never auto-populate safety-critical fields.)