Document decisions and care

Quality statement 7

A patient with a PIVC will have documentation of its insertion, maintenance and removal, and regular review of the insertion site.

Purpose

To ensure that the plan of care for a patient’s PIVC is clear and that decisions relating to the PIVC and its condition are accurately recorded and accessible to all clinicians involved in the patient’s care.

What the quality statement means

For patients

Information about your PIVC will be discussed with you and recorded in your healthcare record or chart. This may include why the PIVC is needed, the type of PIVC, when it was inserted and by whom, its location, the therapy you are receiving, when the PIVC is expected to be removed and when it is actually removed. Your PIVC will be checked regularly and the findings will be noted down. If complications develop, the complications and what your clinician did about them will also be recorded. This will help your healthcare team to be aware of decisions made about your PIVC and any problems that arise.

For clinicians

Ensure that the plan of care for a patient’s PIVC is recorded according to local policy in a place that is easily accessible to all clinicians involved in the patient’s care.

For health service organisations

Support clinicians to maintain accurate and complete healthcare records about a patient’s infusion therapy by ensuring that organisational policies and procedures describe the complete requirements for documentation, where to document and how often documentation should occur.

At a minimum, documentation should include information about inserting, maintaining and removing PIVCs, and reviewing the insertion site.

If an electronic system is used for records, ensure that it captures the date and time of insertion, and confirms that the PIVC has been removed before the patient is discharged from hospital. Details about any adverse events such as infection, infiltration or extravasation, and the actions taken to deal with them, should also be documented.

Ensure that complete and accurate healthcare records are available at the point of care so that all clinicians involved in the patient’s care are aware of the plan for the patient’s infusion therapy. Monitor documentation procedures to ensure that they adhere to the organisational process, and provide feedback to clinicians as part of ongoing quality improvement.

For patients

Information about your PIVC will be discussed with you and recorded in your healthcare record or chart. This may include why the PIVC is needed, the type of PIVC, when it was inserted and by whom, its location, the therapy you are receiving, when the PIVC is expected to be removed and when it is actually removed. Your PIVC will be checked regularly and the findings will be noted down. If complications develop, the complications and what your clinician did about them will also be recorded. This will help your healthcare team to be aware of decisions made about your PIVC and any problems that arise.

For clinicians

Ensure that the plan of care for a patient’s PIVC is recorded according to local policy in a place that is easily accessible to all clinicians involved in the patient’s care.

For health service organisations

Support clinicians to maintain accurate and complete healthcare records about a patient’s infusion therapy by ensuring that organisational policies and procedures describe the complete requirements for documentation, where to document and how often documentation should occur.

At a minimum, documentation should include information about inserting, maintaining and removing PIVCs, and reviewing the insertion site.

If an electronic system is used for records, ensure that it captures the date and time of insertion, and confirms that the PIVC has been removed before the patient is discharged from hospital. Details about any adverse events such as infection, infiltration or extravasation, and the actions taken to deal with them, should also be documented.

Ensure that complete and accurate healthcare records are available at the point of care so that all clinicians involved in the patient’s care are aware of the plan for the patient’s infusion therapy. Monitor documentation procedures to ensure that they adhere to the organisational process, and provide feedback to clinicians as part of ongoing quality improvement.

Read quality statement 8 - Routine use: inspect, access and flush