Documentation Flashcards

For CLABSI surveillance purposes, which documentation element links a bloodstream infection to a specific central line?

Answer: Catheter type, insertion date, insertion site, and days in place at time of infection

NHSN CLABSI definitions require documentation of catheter characteristics and dwell time to attribute a BSI to a specific central line and trigger appropriate surveillance.

When documenting the rationale for VAD selection, which criterion BEST demonstrates evidence-based decision-making?

Answer: Anticipated therapy duration, osmolarity of infusate, and patient anatomy/vein assessment findings

Evidence-based VAD selection documentation should reflect clinical decision criteria including therapy duration, vesicant/irritant potential, and vascular assessment findings.

A PICC is found to have migrated 3 cm externally since the last measurement. What is the PRIORITY documentation action?

Answer: Record the new external length, compare to insertion documentation, notify the provider, and document the response

External migration must be documented with measurements compared to baseline, provider notification recorded, and all subsequent orders or imaging results noted to track catheter position.

In home infusion nursing, which regulatory body's standards most directly govern vascular access documentation requirements?

Answer: The Accreditation Commission for Health Care (ACHC) or Joint Commission (TJC) home care standards

Home infusion agencies accredited by ACHC or TJC must meet those bodies' documentation standards for vascular access, which align with INS practice standards.

A nurse uses topical lidocaine before PICC insertion. What must be documented regarding its use?

Answer: Drug name, dose, site of application, time applied, patient response, and any allergic reactions

All medications, including topical anesthetics, must be documented in the medication administration record with standard medication documentation elements and patient response.

A nurse makes a late documentation entry for a vascular access assessment performed 4 hours earlier. Which practice is MOST appropriate?

Answer: Enter current date/time, clearly label as 'late entry,' state the time the care was actually provided, and document the clinical findings

Late entries must be labeled as such with both the actual time of care and the time of documentation to maintain record integrity and avoid falsification.

Which documentation practice BEST supports detecting catheter-associated complications over time?

Answer: Consistent use of a standardized assessment tool with dated serial entries for each access site evaluation

Serial, standardized documentation of site assessments creates a trend record that enables early identification of complications such as phlebitis, infiltration, or infection.