Documentation Flashcards

When documenting PICC tip placement confirmed by chest X-ray, which anatomical landmark should be recorded as the target location?

Answer: Superior vena cava/cavoatrial junction

The ideal PICC tip position is at the superior vena cava/cavoatrial junction, and this must be documented along with the method of confirmation.

Which element is MOST critical to document when a patient refuses vascular access education prior to discharge?

Answer: The patient's stated reason for refusal and that risks of non-compliance were explained

Documenting the reason for refusal and that risks were communicated creates a legally defensible record and satisfies informed refusal requirements.

A nurse draws blood from a central venous catheter and discards the first 5 mL. What must be documented regarding this discard?

Answer: Amount discarded and that waste was witnessed per policy

Discard volumes from CVCs must be documented along with witness verification to comply with controlled substance and institutional waste policies.

How should multiple failed venipuncture attempts be documented in the medical record?

Answer: Number of attempts, sites tried, gauge used, and reason for difficulty

Each attempt should be documented with anatomical site, needle gauge, number of attempts, and contributing factors to ensure continuity and legal protection.

When documenting a CVC dressing change, which observation is MOST important to include about the insertion site?

Answer: Presence or absence of erythema, drainage, tenderness, and catheter securement integrity

Site assessment findings including signs of infection or complications must be recorded each time a dressing change is performed to track trends and ensure early intervention.

Which information about IV flow rate is MOST important to document after initiating an infusion?

Answer: Prescribed rate, actual rate set, and infusion pump ID or type used

Documenting prescribed rate, actual programmed rate, and the pump used creates accountability and supports error detection if a rate discrepancy occurs.

A peripheral IV is removed due to phlebitis. Beyond documenting removal, what must the nurse record?

Answer: Phlebitis grade using a validated scale, site appearance, treatment initiated, and patient response

Using a validated phlebitis grading scale and documenting treatment and patient response ensures standardized assessment and supports quality improvement tracking.