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Documenting IV Therapy

By Kelli Rosenthal, MS, RN, BC, CRNI, ANP, APRN, BC

Infusion therapy-related lawsuits are among the fastest-growing category of litigation brought against nurses. Because of the invasive nature of IV therapy, patients may experience unexpected outcomes, whether or not the care they received was diligently provided. How you document the IV care you provided can clearly identify the difference between malpractice and misadventure. Your documentation must demonstrate to anyone reviewing it later that the care you provided met the standard of care.

Standards published by the Infusion Nurses Society set the bar for intravenous therapy practices by nurses in all settings. Your institutional policies and procedures should reflect current INS Standards. According to the Infusion Nursing Standards of Practice, documentation should include:

  • Type, length, and gauge of the catheter inserted
  • Date and time of insertion
  • Number/location of attempts
  • Name of the vein
  • Type of dressing applied to the site
  • How the patient tolerated the procedure
  • Name of the person inserting the device.
  • Also document:

  • Specific safety or infection control precautions
  • Relevant patient and caregiver education
  • Any barriers to care or complications that occur
  • Any comments made by the patient about the insertion
  • The infusates delivered through the IV
  • Definitely document any deviations from policy and the reasons for same, since hospital policy will be used as a standard to benchmark your care.
  • On an ongoing basis, document the patientís tolerance of the therapy, site condition and appearance (include standardized scales for phlebitis and/or infiltration/extravasation), site care, and reinforcement of the patient/family teaching. Frequency of site checks and catheter rotation should be set by written policy and reflect the practice area, since recommendations differ with different patient ages and conditions.

    A tip for nursing documentation: DONíT DOCUMENT WHAT YOU DONíT SEE. In other words do not use phrases such as "no swelling, no redness, no leakage observed". These phrases have not held up in courts of law, and a creative plaintiff attorney can make it appear that you did not assess the patient for anything else! Use instead, "No signs and symptoms of IV-related complications observed," noting a grade of "0" on standardized scales, if that is the case.

    Also make sure you document any:

  • IV starts and site rotations
  • Dressing changes
  • Tubing changes
  • Addition of a new container of solution
  • Change in orders
  • Site checks
  • Medication administration
  • Complications (and your interventions)
  • IV-related communication with other healthcare professionals
  • Volume inclusion on intake and output
  • Discontinuance of therapy, recording the condition of the catheter upon d/c.
  • For more important and useful information on related legal issues see Minimizing the Risk of IV-Related Lawsuits.

    References

    Intravenous Nurses Society: "Intravenous Nursing Standards of Practice," Journal of Intravenous Nursing. 23(Suppl, 63), November/December 2000.

    Brent, N. (1997). Nurses and the law: a guide to principles and application. Phladephia: W.B. Saunders.

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