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NURSING DOCUMENTATION

AND QUALITY
MANAGEMENT IN IVT

PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH


Forms Used in IV Therapy

1. IV Fluid Sheet
2. Medication and Treatment Sheet
3. Blood Transfusion Sheet
4. Flowcharts
5. Endorsement Sheets

PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH


WHAT TO DOCUMENT
A. During Initiation of IV Therapy
1. Size, length and type of device
2. Name of person inserting the device
3. Date and time
4. Site location
5. Type of solution and any additives
added
6. Flow rate
PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH
7. Use of an electronic infusion device of
other type of flow controller
8. Complications
9. Patient response
10. Nursing Interventions
11. Patient teachings, evidence of patient
understanding

PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH


B. During Maintenance of IV Therapy
1. Condition of the site
2. Site care provided
3. Dressings changes
4. Tubing and solution changes
5. Teaching and evidence of patient
understanding.

PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH


C. During termination of IV Therapy
1. Date and time
2. Reason for discontinuing therapy
3. Assessment of the site before and after
venous access device is removed.
4. Complications
5. Patient reactions
6. Nursing Interventions
7. Integrity of the venous device on removal
8. Follow-up
PHILIPPINE actions.
HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH
DOCUMENTATION DO'S AND
DON'TS
1. Do document what you observed first
hand, what the patient said and what
was done - not your opinions.

Don't write: Patient tolerated procedure well.


Instead write: That was painful but I'm
relieved now

PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH


DOCUMENTATION DO'S AND
DON'TS
2. Do write No IV-related complications
observed to document your assessment
of a complication-free venous access site.
If you include specific observations
such as no redness or swelling and not
others, you could be accused of skipping
some assessments.

PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH


DOCUMENTATION DO'S AND
DON'TS
3. Do give details about complications.
Document nursing interventions,
physicians orders, patient comments
regarding complication, and the patient's
response to treatment.

PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH


DOCUMENTATION DO'S AND
DON'TS
4. Don't write catheter tip intact when you
remove a peripheral venous access
device.
Unless you examine it under a
microscope, you can't legitimately make
this statement.

PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH


DOCUMENTATION DO'S AND
DON'TS
5. Don't rely sole on charting by exception
or check-off flow sheets to document.
They don't prove proper patient
assessment and may not hold up in
court.

PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH


DOCUMENTATION DO'S AND
DON'TS
6. Definitely document any deviations from
policy and the reasons for same, since
hospital policy will be used as standard
to benchmark your care.

Example: Extending the duration of a well-


running and patent IV line because the
patient has an exhausted venous
system.

PHILIPPINE HEART CENTER DIVISION OF NURSING EDUCATION & RESEARCH