Documentation Flashcards
7 cards from real VA-BC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation flashcards as text
Before inserting a PICC in a competent adult patient, which documentation must be completed FIRST?
Answer: Signed informed consent including risks, benefits, and alternatives
Informed consent must be obtained and documented before any invasive procedure, including PICC insertion, to uphold patient autonomy and legal standards.
Which timeframe is most commonly required by regulatory standards for completing procedure documentation after PICC insertion?
Answer: Before the patient leaves the procedure area or within the same shift
Most accrediting bodies and institutional policies require procedure notes to be completed before the patient leaves or promptly within the same shift to ensure accuracy.
A patient develops a suspected catheter-related bloodstream infection (CRBSI). Which documentation action is MOST important to initiate immediately?
Answer: Document symptom onset time, cultures obtained, catheter characteristics, and notification of the physician
Immediate documentation of clinical findings, specimens collected, and provider notification creates a timeline critical for infection tracking and CLABSI surveillance.
Central line bundle compliance requires documentation of which element at EVERY dressing change?
Answer: Daily necessity review and whether the line is still required
Central line bundles include daily review of line necessity; documenting this decision is required to support early removal and reduce CLABSI risk.
When documenting a catheter flush using the SASH protocol, which detail is LEAST acceptable to omit?
Answer: Volume and type of solution used for each flush step
SASH documentation requires recording each solution type and volume (saline, antibiotic lock if applicable, saline, heparin) to verify protocol adherence and detect errors.
When a central venous catheter is removed, which finding must be included in the documentation to confirm complete removal?
Answer: Catheter length intact, tip intact, and hemostasis achieved at the site
Documenting that the entire catheter was removed intact, including tip integrity, and that hemostasis was achieved is essential to rule out catheter fracture or embolism.
During a routine vascular access site assessment, the nurse notes no blood return from a PICC. How should this finding be documented?
Answer: Absence of blood return noted, flush resistance assessed, troubleshooting steps taken, and clinician notified if unresolved
Absence of blood return is a clinical finding that must be documented along with troubleshooting actions, as it may indicate catheter malposition, thrombosis, or fibrin sheath formation.