Vascular Access Procedure Note (IV/IO)

Procedure: [IV access / IO access / both]

Date/Time: [Actual procedure start time]

Location: [Care setting and specific location]

Operator(s): [Inserter name and role; supervisor if applicable]

Urgency: [emergent / urgent / non-emergent]

Indication and Purpose

[Clinical indication and intended purpose] (Brief paragraph describing why vascular access was required, including pertinent context such as hemodynamic status, need for rapid access, medication/fluids/blood products delivery, blood draw needs, and prior failed access attempts by others with count if known. If access was used immediately, state what was initiated and approximate time; reference the MAR for detailed infusion parameters.)

Consent

[informed consent (verbal) / informed consent (written) / surrogate consent (verbal) / surrogate consent (written) / emergent or implied consent / consent not required per local policy] (If emergent or implied, include brief justification. If consent not required per policy for low-risk IV, cite policy category.)

Time-Out

[Time-out performed / Time-out omitted] (Include only for IO placement, ultrasound-guided IV, or if required by local policy. If performed, include timestamp and participants. If omitted, briefly state reason and note any verification steps performed to the extent feasible. Omit this section entirely for routine uncomplicated peripheral IV if local policy permits.)

Contraindications Reviewed

[Contraindication screening summary] (For IO: document review of nearby fracture, overlying infection/burn, recent IO in same bone, and prosthetic joint; if a relative contraindication was present yet IO was placed, briefly justify why benefits outweighed risks. For peripheral IV: include only if limb restrictions are relevant such as AV fistula or prior lymph node dissection. If screening was not completed due to life-threatening emergency, state this explicitly. Omit this section for routine peripheral IV without limb restrictions.)

Preparation and Technique

[Site and side selected; rationale if nonstandard] [Skin antisepsis agent] [Sterile vs clean technique] [Local anesthesia if used] [For conscious IO: analgesia agent/dose or reason omitted] [Guidance method: landmark vs real-time ultrasound guidance] (If ultrasound guidance was used, note "real-time ultrasound guidance" here; detailed documentation goes in the Ultrasound Addendum if needed for billing.)

Attempt Log

• Attempt [#]: [Time] — [Method: IV landmark / IV ultrasound-guided / IO drill / IO manual]; [Site and side]; [Device: gauge and length for IV, or needle size for IO] — Outcome: [success / failed]. (If failed, specify reason: no flash, unable to thread, infiltration, patient movement, landmark difficulty, equipment issue, or other. Multiple rapid failed attempts at the same site may be summarized if site/side and count remain clear. Any attempt with a complication must be documented separately. Use "Unknown / not available in record" for device details if not documented.)
• (Add additional entries for each attempt.)

Successful Access

(Include this section only if access was successfully obtained.)

• Access type: [IV / IO]
• Site and side: [Anatomic location and laterality]
• Device: [IV gauge and length / IO needle size]
• Total attempts to success: [Number]
• Immediate function: [saline lock / continuous infusion / pressure bag infusion]
• Blood drawn via this access: [yes / no]

Confirmation of Placement

[Confirmation elements observed] (Document at least two elements. For IV: blood return observed, flushes without resistance, no pain/swelling/coolness during flush. For IO: marrow aspiration obtained or "aspiration attempted, not obtained," flushes easily, infusion flows under pressure without extravasation, needle stable and secured. For IO, also document distal neurovascular status if feasible. If patency cannot be confirmed, explicitly state "patency not confirmed" and document immediate actions taken.)

Complications

Complications: [None / Present]

(If present, document: type [infiltration / extravasation / hematoma / arterial puncture / severe pain / fracture / compartment syndrome concern / device malfunction / other]; timing [during attempt / after use began]; clinical findings; interventions performed [line discontinued / aspiration attempted / elevation / compress applied / antidote protocol with agent specified / surgical or specialty consult / new access obtained]; and line disposition [removed / replaced / continued with monitoring]. State exactly what was done; avoid generic phrases.)

Post-Procedure

• Dressing and securement: [Type of dressing and securement method]
• Patient tolerance: [well tolerated / discomfort noted / sedation used]
• Site appearance after securement: [no bleeding / minimal oozing / hematoma / swelling / other]
• For IO — Transition plan: [Plan for peripheral or central access]. Neurovascular monitoring: [Frequency and parameters].
• If removed during encounter: Removal time [time]; reason [reason]; site condition [condition]; hemostasis/dressing [method].

Ultrasound Addendum

(Include only if ultrasound guidance was used and documentation is needed for billing or medicolegal support.)

• Ultrasound evaluation of potential access sites: [performed / not performed]. Selected vessel: [compressible / patent / adequate caliber].
• Real-time visualization of needle entry and cannulation: [yes / site marking only — no real-time guidance].
• Permanent image/video saved to record: [yes / no]. Storage location: [PACS / EMR media library / device archive].