Peripheral IV Insertion/Removal Procedure Note

Procedure Date/Time: [Procedure date and exact time]

Procedure Type: [insertion / removal / insertion and removal] [Ultrasound-Guided, if applicable]

Location/Setting: [ED / inpatient unit / ICU / clinic / radiology / other]

Clinician Performing: [Full name, credentials, role]

Indication

[Brief clinical reason for current IV access need or removal] (State the specific indication such as IV medications, fluids, blood products, contrast, or anticipated clinical course. For removal, state reason such as therapy complete, complication suspected, routine replacement, or patient request. If prior failed attempts or difficult access prompted escalation, note the number of prior attempts and escalation pathway.)

Consent

[Consent status: verbal consent obtained / implied consent with patient cooperation / emergent—proceeded in patient's best interest / patient lacks capacity—proceeded per policy / refusal documented] (Do not infer consent. If not addressed in dictation, state "Consent status not documented." If refused, document refusal and disposition.)

Aseptic Technique

• [Hand hygiene performed: yes / no / not documented]
• [Glove type: clean / sterile / not documented]
• [Skin antiseptic agent: chlorhexidine-alcohol / alcohol / povidone-iodine / antiseptic agent not recorded] [Allowed to dry before cannulation: yes / not documented]
• [No-touch technique maintained after skin prep: yes / no / not documented]

Insertion Details

(Include only if insertion was performed or attempted.)

• Site: [left / right] [hand / forearm / antecubital / upper arm / other] [Vein name if known]
• Catheter gauge (required): [Gauge] [Length if stated] [Power-injectable: yes / no, if relevant to indication]
• Technique: [landmark / ultrasound-guided / infrared vein finder] (If ultrasound-guided, complete the Ultrasound Addendum.)
• Attempts: [Number of attempts by this clinician] [Sites attempted if multiple] (If a site was abandoned, briefly note reason: no flash, infiltration, vein blew, patient discomfort.)
• Escalation: [not applicable / escalated to higher-level operator or vascular access service after unsuccessful attempts]
• Placement confirmation: Blood return [yes / no]. Flush [flushes without resistance / resistance noted / not tested—reason]. Signs of infiltration at placement [none / present—describe]. (Do not infer patency if not tested.)
• Local anesthesia: [none / topical anesthetic / intradermal lidocaine—dose] (Include only if used.)

Ultrasound Addendum

(Include only if ultrasound was used.)

• Ultrasound use: [pre-scan vessel assessment only / real-time needle guidance]
• Infection prevention: [Sterile single-use gel used per CDC 2025 guidance: yes / no] [Probe cover used: yes / no] [Probe cleaned per facility protocol: yes]
• Difficult access criteria: [no visible or palpable veins / multiple failed attempts / known difficult access / other]

Dressing and Securement

(Include only for successful insertion.)

[Dressing type: transparent semipermeable / gauze]. [Securement method: adhesive securement device / sutureless stabilization / tape]. [Site labeled with date/time/initials: yes / no]. [Extension set or needleless connector placed: yes / no].

Removal Details

(Include only if removal was performed.)

• Date/time of removal: [Date and time]
• Catheter withdrawal: [withdrawn without difficulty / difficulty encountered—describe]
• Hemostasis: [Achieved with direct pressure for approximately ___ minutes] [Dressing applied: adhesive bandage / gauze and tape / transparent dressing]
• Catheter inspected and intact: [yes / no—immediate escalation initiated, document actions and patient status] (This confirmation is required.)
• Post-removal site assessment: [No redness, swelling, drainage, or tenderness / Abnormalities noted—describe]

Complications

[No immediate complications] OR [Complication(s) occurred: hematoma / suspected arterial puncture / nerve symptoms / infiltration or extravasation / vasovagal episode / other—describe management, patient status after intervention, and any escalation] (Always include this section.)

Disposition

[Line status: saline lock / continuous infusion / removed]. [Patient tolerance: tolerated well / mild discomfort / other]. [Specific monitoring instructions if high-risk situation] (Include monitoring only if explicitly stated.)

Signature

Electronically signed by [Name], [Credentials] on [Date/Time]. (If documented after the fact, label as late entry with actual procedure time and documentation time.)

(Omit sections cleanly when they do not apply. Omit supervising physician attestation and time-out documentation unless explicitly dictated.)