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
Intracavitary ECG (IC-ECG) is used to confirm PICC tip placement. What must the documentation include to validate this method?
Answer: Waveform findings at insertion, P-wave morphology changes noted, and final tip position interpretation
IC-ECG confirmation documentation must describe the biphasic or peaked P-wave transition that signals cavoatrial junction positioning to be clinically valid.
A patient experiences suspected air embolism during central line disconnection. Beyond emergency interventions, which documentation element is MOST critical?
Answer: Exact time of event, symptoms observed, interventions performed in sequence, and patient response
Air embolism is a life-threatening event requiring precise chronological documentation of symptoms, interventions, and outcomes to support clinical care and risk management review.
When accessing an implanted port, which documentation element confirms appropriate access technique?
Answer: Non-coring needle type and gauge, blood return confirmed, port palpated and accessed per protocol, and post-access site assessment
Port access documentation must include non-coring needle specifics, blood return confirmation, and site assessment to verify correct technique and device integrity.
A PICC catheter is repaired using an approved repair kit. Which documentation is REQUIRED after the repair?
Answer: Reason for repair, kit lot number, repair site on catheter, post-repair blood return and flush assessment, and provider notification
Catheter repair must be fully documented including the repair kit used, location of damage, and post-repair functional assessment to ensure the repair met safety standards.
When an IV infusate is changed from a hyperosmolar solution to a standard isotonic solution via a PICC, what must be documented?
Answer: Previous infusate, new infusate, rate change if applicable, flush performed between infusates, and time of change
Documenting the transition between infusates—including any flush performed—ensures the record reflects actual therapy delivered and supports accurate medication reconciliation.
After a needlestick injury during vascular access insertion, which documentation pathway is MANDATORY in addition to the patient's medical record?
Answer: An institutional incident/occurrence report submitted to employee health or risk management per OSHA and facility policy
OSHA's Bloodborne Pathogen Standard mandates that needlestick injuries be reported through an institutional incident reporting system independent of the clinical chart, regardless of source patient status.
A patient with a history of multiple failed peripheral IV attempts presents for IV therapy. Which documentation from previous encounters would be MOST valuable for the current vascular access plan?
Answer: Sites attempted, devices used, complications encountered, and any recommendations made by a vascular access specialist
Prior access history documenting failed sites and specialist recommendations directly guides current VAD selection and reduces unnecessary patient discomfort from repeated attempts.