Vascular Access Procedure Note (PICC/Central Line)

Date/Time: [Start time — End time]

Location: [Unit/Department] — [bedside / procedural suite]

Operator: [Name, credentials]

Procedure: [PICC / non-tunneled CVC]

Urgency: [elective / urgent / emergent]

Indication

[Clinical necessity and intended use] (Include rationale for device type or access site selection if nonstandard.)

Consent and Time-Out

Informed consent: [obtained from patient / obtained from surrogate / verbal consent / written consent / consent waived due to emergency] — [rationale if waived or surrogate used]

Time-out: [performed immediately prior to puncture, confirming correct patient, procedure, and site/side / not performed] (If not performed, document why and mitigation steps taken.)

Pre-Procedure

• Patient positioning: [Position description]
• Monitoring: [Monitoring modalities in use]
• Skin preparation: [Agent] — dry time observed: [yes / no]
• Maximal sterile barrier: [cap, mask, sterile gown, sterile gloves, full body drape] (If any element omitted, document reason and follow-up plan.)
• Local anesthesia: [Agent, concentration, volume]
• Sedation: [Agent, dose, route] (Include only if administered.)

Procedure Details

Access site: [right / left] — [Anatomic location] — [Approach description]

Imaging guidance:

• Ultrasound: [used / not used] (If used, document: vessel patency and compressibility findings, real-time needle visualization confirmed, images saved per policy.)
• Fluoroscopy: [used / not used] (If used, include fluoroscopy time if available. If contrast used, document agent and volume.)

Technique:

• Cannulation method: [Technique description]
• Puncture attempts: [Number]
• Venous access confirmation: [Method used to confirm venous entry]
• Guidewire: [advanced without resistance / resistance encountered — describe management]
• Tract dilation: [performed / not applicable]
• Catheter advanced to measured depth: [yes / no] — [Insertion depth]
• Guidewire status: [Removed intact and accounted for] (Always document explicitly. If not removed intact, document immediate actions taken.)
• Multiple sites attempted: [no / yes — document each site and reason abandoned]

Catheter details:

• Configuration: [Number of lumens]-lumen, [French size] Fr, power-injectable: [yes / no]
• Lengths (PICC): Total length [cm], trimmed to [cm], internal length [cm], external length [cm]
• Depth (CVC): [Insertion depth at skin]
• Securement: [Securement method]
• Dressing: [Dressing type]

Tip Confirmation and Line Status

• Tip confirmation method: [post-procedure chest radiograph / fluoroscopy / intracavitary ECG / other / pending]
• Tip position: [Position description, e.g., lower SVC or cavoatrial junction] (Include only if confirmed; do not infer.)
• Pneumothorax assessment: [no pneumothorax / pneumothorax present / pending] (For IJ or subclavian/axillary placements.)
• Line clearance status: [Cleared for use including vasopressors, TPN, and vesicants as indicated / NOT cleared for vesicants, vasopressors, or TPN until tip confirmation complete — interim permitted uses: specify]

(Do not omit this section if confirmation is pending; explicitly state pending status and use restrictions.)

Complications

[None / List each complication with timing and management] (Always include this section even if none. Do not infer—only document observed complications.)

Post-Procedure Care

• Estimated blood loss: [mL]
• Patient tolerance: [Well tolerated / describe if otherwise]
• Dressing care: [Care instructions and change interval]
• Flush and lock: [Solution, volume, frequency per local protocol]
• Permitted uses once cleared: [Specify whether power injection and blood draws permitted]
• Line necessity: Review daily with prompt removal when no longer needed
• Follow-up required: [Pending imaging or reassessment and responsible party] (Include only if applicable.)

(Safety-critical documentation: If consent, time-out, sterile technique elements, or guidewire status were not performed or are missing, do not omit—explicitly document what occurred with rationale and mitigation.)