IV Initiation Documentation
Key Points
- IV initiation charting must be complete, specific, and time-linked to the procedure.
- Required fields include device details, site characteristics, attempts, and patient tolerance.
- Documentation must include infusion status, patency, and follow-up integrity per policy.
Equipment
- EHR or approved documentation platform
- Procedure details from insertion workflow (device, gauge, site, dressing, infusion setup)
- Policy reference for required IV charting fields
Procedure Steps
- Record date and time of IV initiation immediately after successful insertion (preserves event accuracy).
- Document device manufacturer/brand, catheter gauge and length, and exact accessed vein/site description.
- Record key procedural details: use of local anesthetic, number of attempts, site/extremity condition, and securement/dressing type.
- Chart immediate outcome including blood return, saline flush/clamp status, and whether the line is saline locked or infusing.
- If infusion started, document method (gravity or pump), fluid/medication type, and ordered rate.
- Document patient tolerance, education provided, and ongoing integrity/patency assessment per agency policy.
Common Errors
- Vague site or device documentation → weak continuity of care and higher troubleshooting risk
- Missing attempts/tolerance/patency details → incomplete safety record and medicolegal vulnerability
Related
- peripheral-iv-access - Accurate charting follows safe insertion and maintenance practices.
- iv-insertion-and-iv-removal - Documentation expectations continue through line discontinuation.