Documentation Flashcards
7 cards from real VABC 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
When an implanted port is accessed, documentation should include all of the following EXCEPT:
Answer: Number of previous port accesses in patient's lifetime
The total historical access count is not a required documentation element; current procedural details and patient response are what must be recorded.
Which action best reflects accurate documentation when a central line-associated bloodstream infection (CLABSI) is suspected?
Answer: Document signs/symptoms, notify provider, and record actions taken
Suspected CLABSI requires prompt documentation of clinical signs, provider notification, and all interventions in real time to support patient safety and surveillance.
For a midline catheter insertion, which measurement must be documented to distinguish it from a PICC?
Answer: Catheter length inserted and external length
Recording the inserted and external catheter lengths confirms the tip does not extend beyond the axillary vein, distinguishing the midline from a PICC.
A patient reports pain at a peripheral IV site. What is the FIRST documentation priority?
Answer: Document the pain score and site assessment findings
An immediate record of the patient's pain complaint, pain score, and site assessment findings establishes a baseline and guides further intervention.
Which grading scale is most commonly documented when assessing peripheral IV phlebitis?
Answer: Visual Infusion Phlebitis (VIP) Scale
The Visual Infusion Phlebitis (VIP) Scale provides a standardized 0–5 grading system for documenting phlebitis severity at peripheral IV sites.
When is it appropriate to use abbreviations in vascular access documentation?
Answer: Only when abbreviations are on the facility's approved list
Only facility-approved abbreviations should be used in documentation to reduce misinterpretation and comply with accreditation standards.
What is the primary purpose of documenting the external catheter length after each assessment of a PICC?
Answer: To detect catheter migration over time
Comparing the current external length to the insertion baseline helps detect inward or outward catheter migration that could affect tip position.