DOCUMENTATION IN

IV THERAPY

Submitted by: Jhen Mich Q. Lagos

Submitted to: Mrs. Myrvi P. Vergara RN, MAN
COURSE DESCRIPTION

• This lecture is aimed to focus on documentation during

IV Therapy with adherence to standards of practice and
guidelines.
 GENERAL
OBJECTIVE

• To understand the standards in IV therapy

documentation and reporting in accordance to infusion
therapy standards of practice.
Standards are the level of quality
care that is considered acceptable What are standards of care?
or desirable.

Standards of care are based on the

skill, care, and judgment used by an
average health care provider under
similar situation. (Ferrell, 2007)
Standards of care are
determined by: – Practice acts

– State and federal regulatory

agencies

– Joint Commission

Documentation validates that these – Organizational policies

standards are followed and assists
with continuity of care among the
health care team.
– Specialty organizations
 Each standard consists of two
1. Standards. The Standards
are expectations of practice
applicable to infusion therapy
in all settings.
components:
2. A standard is defined as an
authoritative statement
enunciated and promulgated
by the profession by which
the quality of practice,
service, or education can be
judged (American Nurses
Association, 2014; Gorski et
al., 2016b).
PRACTICE CRITERIA

Practice Criteria - provide

specific guidance in the
implementation of the
corresponding Standard.
Each Practice Criterion is
supported by evidence, is
rated as reflecting the
strength of the body of
evidence.
NURSING DOCUMENTATION

• Best evidence of
appropriate care done to
the client and SO.
• It reflects client care
provided on the basis of
assessment data and the
clients response to
interventions
• Provides a way for health
team professionals to
PRIMARY PURPOSE
communicate with each other.
• Provides a legal record that
OF CHARTING
can be used to protect the
patient, the health professional
and health facility who
provide care.
• Provides data needed for
effective interdisciplinary care
to ensure continuity of care.
• Provides a record of service
PRIMARY PURPOSE
rendered and equipment used
for cost accounting and OF CHARTING
reimbursement
• Charting is mandated by
Department of Health (DOH)
GENERAL
PRINCIPLES OF
DOCUMENTATION
• ACCURAT
E
• COMPLET
E
• FACTUAL
• CLEAR
• CONCISE
 INFUSION
THERAPY
STANDARDS OF
PRACTICE
REVISED 2021
INFUSION THERAPY STANDARDS OF PRACTICE
STANDARDS OF DOCUMENTATION 2016
10. Infusion therapy Practice Standard

10.1 Clinicians document their initial and

ongoing assessments or collection of
data, diagnosis or problem, intervention
and monitoring, the patient’s response to
that intervention, and plan of care for
infusion therapy. Expected side effects
and unexpected adverse events that occur,
with actions taken and patient response,
are documented.
10. Infusion therapy Practice Standard

10.2 Documentation contains accurate,

complete, chronological, and objective
information in the patient’s health record
regarding the patient’s infusion therapy
and vascular access with the clinician’s
name, licensure or credential to practice,
date, and time.
10. Infusion therapy Practice Standard

10.3 Documentation is legible, timely,

accessible to authorized personnel, and
efficiently retrievable.

10.4 Documentation reflects the

continuity, quality, and safety of care.
10. Infusion therapy Practice Standard
10.5 Documentation guidelines and the
policies for confidentiality and privacy of
the patient’s health care information and
personal data are established in
organizational policies, procedures,
and/or practice guidelines according to
the scope of practice for individuals with
specific licensure or credentials,
standards of care, accrediting bodies, and
local/national laws.
 INFUSION
THERAPY
STANDARDS OF
PRACTICE
REVISED 2021
Infusion Nursing Standards of Practice 2016
Practice criteria
 PRACTICE CRITERIA
PRACTICE RECOMMENDATIONS

A. Documentation includes patient, caregiver, or surrogate’s consent or assent to vascular

access device (VAD) insertion, as appropriate, and their participation in or understanding of
VAD related procedures but not limited to the following:

1. Patient responses to VAD insertion and removal procedures.

2. Patient responses to VAD access and/or infusion therapy, including symptoms, side
effects, or adverse events.
3. Patient, caregiver, or surrogate understanding of VAD- and infusion therapy-related
education or barriers to that education.1-5 (I)
 PRACTICE CRITERIA
PRACTICE RECOMMENDATIONS

B. Include the following in documentation for vascular access and/or VAD-related procedures:

1. A standardized tool for documenting adherence to recommended practices, such as specific

site preparation, infection prevention, and safety precautions taken.6-12 (IV)
2. Related to VAD insertion: indication for use, date and time of insertion, number of attempts;
type, length, and gauge/size of VAD inserted; functionality of device, identification of the
insertion site by anatomical descriptors, laterality, landmarks, or appropriately marked
drawings; lot number for all CVADs and implanted devices; type of anesthetic (if used); and
the insertion methodology, including visualization and guidance technologies.10,11,13-16
(V)
 PRACTICE CRITERIA
PRACTICE RECOMMENDATIONS

B. Include the following in documentation for vascular access and/or VAD-related procedures:

3. Related to each regular assessment of the access site or VAD: condition of the site, dressing,
type of catheter securement, dressing change, site care, patient report of discomfort/pain, and
changes related to the VAD or access site.5,16 (V)

4. A standardized assessment for signs and symptoms of phlebitis, infiltration, and extravasation
that is appropriate for the specific patient (eg, age or cognitive ability) with photography as
needed and in accordance with organizational policy. This also allows for accurate and reliable
evaluation on initial identification and with each subsequent site assessment (see Standard 9,
Informed Consent).3,5,14-18 (IV)
 PRACTICE CRITERIA
PRACTICE RECOMMENDATIONS

B. Include the following in documentation for vascular access and/or VAD-related procedures:

5. Type of therapy, including flushing or locking, drug, dose, rate, time, route, and method of
administration, including vital signs and laboratory test results as appropriate; condition of the
venipuncture or VAD site prior to and after infusion therapy.2,10 (V)

6. Findings of assessment for VAD functionality including patency, absence of signs and
symptoms of complications, lack of resistance when flushing, and presence of a blood return
upon aspiration.5,10,17(V)
 PRACTICE CRITERIA
PRACTICE RECOMMENDATIONS

B. Include the following in documentation for vascular access and/or VAD-related procedures:

7. Type of equipment used for infusion therapy administration; depending on the venue of care,
accountability for maintenance, and replacement of administration sets/add-on devices, as well
as identification of caregiver or surrogate for patient support and their ability to provide this
care.19 (V)
 PRACTICE CRITERIA
PRACTICE RECOMMENDATIONS

B. Include the following in documentation for vascular access and/or VAD-related procedures:

8. Clear indication of solutions and medications being infused through each device or lumen
when multiple VADs or catheter lumens are used. (Committee Consensus)
 PRACTICE CRITERIA
PRACTICE RECOMMENDATIONS

B. Include the following in documentation for vascular access and/or VAD-related procedures:

9. Regular assessment is completed of the need for continuation of the VAD: a. Daily for acute
inpatient settings.5,12,13 (V) b. During regular assessment visits in other settings, such as in the
home, outpatient facility, or skilled nursing facility.20 (V)
 PRACTICE CRITERIA
PRACTICE RECOMMENDATIONS

B. Include the following in documentation for vascular access and/or VAD-related procedures:

10. Upon removal: condition of site; condition of the VAD, such as length of the catheter
compared to length documented at insertion; reason for device removal, interventions during
removal, dressing applied, date/time of removal, any necessary continuing management for
complications; and, if cultures are obtained, source of culture(s).5,10,15 (V)
 PRACTICE CRITERIA
PRACTICE RECOMMENDATIONS

C. Additional documentation related to midline catheters and PICCs includes:

1. External catheter length and length of catheter inserted.19 (V)

2. Circumference of the extremity: at time of insertion and when clinically indicated to
assess the presence of edema and possible deep vein thrombosis. Note where the
measurement is taken and if it is the same area each time. Note presence of pitting or
nonpitting edema.21,22 (IV)
 PRACTICE CRITERIA
PRACTICE RECOMMENDATIONS

D. Documentation includes confirmation of the anatomical location of the catheter tip for
all central vascular access device (CVAD) prior to initial use and as needed for evaluation
of catheter dysfunction or changes in external length of catheter.7 (V)

E. Documentation of required elements of care using standardized templates or tools should

be used (eg, for VAD insertion and infusion therapy), without limiting further description as
needed.3,17,23 (V)
 PRACTICE CRITERIA
PRACTICE RECOMMENDATIONS

F. Complete all documentation in an electronic health record (EHR) or other electronic

health information system, if available, using standardized terminologies and promoting
communication among the health care team.1,24-27 (I)
1. Electronic entries should reflect current patient status, even when an entry is pulled from
another location in the health record.3,28 (V)

2. The EHR should capture data for QI of patient vascular access without additional
documentation from clinicians.3,29-35 (I)
 PERIPHERAL
INTRAVENOUS
THERAPY
Documentation 2/9/99 22:00 20 gauge angiocath inserted
in patient’s right antecubital vein -
Example successful on first attempt – flashback
observed. Inserted for purpose of IV
hydration with normal saline infusing at
150 milliliters per hour. IV fluids infusing
well. No swelling, pain, or hematoma
noted. The patient tolerated the procedure
without any complaints. The patient
verbalizes understanding of signs and
symptoms of intravenous complications,
and to call the nurse if any of these signs or
symptoms should occur--------Janice Smith
RN
Documentation “2/10/05 06:00 20-gauge angiocath
removed from patient’s right antecubital
Example vein due to swelling and tenderness over
site. Catheter tip intact. Sterile 2x2
dressing applied. Patient tolerated well,
without complaints. Warm soaks applied to
right antecubital area and right upper
extremity elevated on 2 pillows.” Janice
Smith RN
 INTRAVENOUS SITE ASSESSMENT SHEET

Infiltration
-common complication of intravenous (IV)
therapy. Common signs include
inflammation, tightness of the skin, and pain
around the IV site.
Phlebitis
- an inflammation of a vein just below the surface of
the skin, which results from a blood clot. may occur
after recently using an IV line, or after trauma to the
vein. Some symptoms can include pain and
tenderness along the vein and hardening and feeling
cord-like.

Extravasation
- leakage of injected drugs from blood vessels
causing damage to the surrounding tissues.
Common symptoms and signs of extravasation
include pain, stinging or burning sensations, and
edema around the intravenous (IV) injection site.
Infiltration

Phlebitis

Extravasation
THANK YOU AND GOD
BLESS !