Vascular Access Documentation: What to Record and When

Vascular access documentation serves clinical, regulatory, legal, and quality purposes. It communicates device status to the care team, demonstrates compliance with insertion and maintenance bundles, enables epidemiologic surveillance (catheter-days for CLABSI reporting), and provides a defensible record in adverse event review.

INS 2021 Standard 71 (Documentation) specifies minimum documentation requirements for vascular access devices across the device lifecycle.

Parent guide: Vascular Access: Complete Clinical Reference

Why Documentation Matters

Clinical communication: The next nurse, physician, or provider caring for the patient needs to know: what device is present, where is it, when was it placed, is it functioning, and when is the next dressing due?

Regulatory compliance: TJC surveyors review catheter insertion documentation for bundle compliance evidence. CMS requires catheter-days tracking for NHSN CLABSI reporting. INS Standards require documentation of specific insertion elements.

Legal defensibility: In the event of a CLABSI event, catheter-associated DVT, or extravasation injury, the medical record is the primary evidence of what was done, when, and by whom.

Quality improvement: Aggregated documentation data enables calculation of CLABSI rates (events / catheter-days × 1,000), bundle compliance rates, and device dwell time benchmarks.

Insertion Documentation

The insertion note must be completed at the time of device placement (or as soon as possible after). Required elements per INS 2021:

Peripheral IV Insertion Note

Date and time of insertion
Site (vein name, laterality, anatomical location)
Catheter gauge and length
Number of insertion attempts
Catheter patency confirmation (blood return; flush with normal saline without resistance or swelling)
Securement method and dressing type applied
Patient tolerance of the procedure
Inserter name and credentials

PICC / Midline Insertion Note

All PIV elements, plus:

Device type and brand (PICC, midline; manufacturer name and catalog number per institutional policy)
Catheter size in French gauge
Number of lumens
External length (from insertion site to hub)
Internal length (calculated from external measurement)
Tip confirmation method (intraprocedural ECG, post-procedure CXR)
Tip confirmation result (position described or radiologist report reference)
Patient consent reference (informed consent obtained; documentation reference)
Maximal sterile barrier compliance confirmation
CHG antisepsis confirmation
Indication for central access documented

CVC / Non-Tunneled Central Catheter Insertion Note

All PICC elements, plus:

Insertion site (IJ vs. subclavian vs. femoral; right vs. left)
Approach (ultrasound-guided vs. landmark; document US guidance)
Guidewire used or not
Any complications during insertion (arterial puncture attempt, pneumothorax workup, multiple attempts)
Post-procedure CXR ordered and result documented

Daily Assessment Documentation

Required frequency: At minimum every shift (or per institutional policy, but no less frequently than every 8–12 hours for inpatients with CVADs).

Required elements (INS 2021):

Date and time of assessment
Site appearance: erythema (redness), swelling/edema, drainage (type, amount, color), tenderness at insertion site
Dressing integrity: dry, occlusive, and intact; or requires change
Securement device condition
Catheter patency: flushed easily; blood return present or absent (document if absent)
External catheter length (for PICCs): compare to documented insertion length; note if any change (may indicate catheter migration)
Device necessity documented: “CVAD still clinically indicated for [reason]” — daily necessity review must be explicit
Dressing changed: yes/no; if yes, document old dressing appearance, antiseptic used, new dressing type and lot/batch if required

Infusion Therapy Documentation

At each administration of medications or fluids via a vascular access device, documentation must include:

Drug name, dose, route, rate, diluent, volume
Start and end time (for infusions)
Patient tolerance
Pre-infusion site assessment result (blood return, no swelling, no pain at site)
Any adverse reactions

For vesicant administration: Document pre-administration site assessment including blood return confirmation, planned access site, monitoring frequency during infusion, and post-infusion site assessment.

Complication Documentation

When a vascular access complication is identified, documentation must capture:

Date and time of identification
Complication type and severity (use validated scales where available: INS phlebitis scale, infiltration staging scale)
Clinical findings (symptoms, objective signs)
Interventions performed (device removal, warm/cold compress, antidote administered, provider notification)
Provider notification: name, time, and response
Patient education provided
Plan for follow-up assessment
Outcome (improvement, no change, escalation)

Device Removal Documentation

At removal of any vascular access device:

Date and time of removal
Reason for removal (therapy complete, complication, no longer clinically indicated, replacement with different device, patient discharge)
Catheter integrity on removal (document if catheter tip appears intact; for CVADs, measure and confirm catheter length matches expected length)
Site appearance at removal
Dressing applied post-removal (for CVADs: occlusive dressing, maintained for ≥30 minutes to reduce air embolism risk)
Any difficulty during removal (resistance, kinking, partial or fragmented removal — if fragmented, this is a critical event requiring immediate escalation)
Patient tolerance

EHR Best Practices

Structured fields vs. free text: Where possible, use structured EHR fields for device type, insertion site, gauge, lumen count, and dressing status — this enables database queries for catheter census and quality reporting.

Catheter census: Many hospitals use EHR-based catheter census tools (lists of all patients with CVADs, including insertion date and device type) to support daily necessity review and NHSN catheter-day counting.

Smart documentation: Some EHRs prompt for PICC insertion documentation immediately after a PICC placement order is completed or at nursing handoff — use these triggers to ensure timely and complete documentation.

Joint Commission Documentation Requirements

TJC surveyors specifically look for:

Evidence of insertion bundle compliance (CHG antisepsis, MSB documentation, indication)
Daily documentation of catheter necessity (“Is this line still needed?”)
Evidence of complication assessment at every dressing change
Documentation of patient/family education on catheter care

References

Gorski LA, et al. (2021). INS Infusion Therapy Standards (Standard 71: Documentation). J Infus Nurs, 44(Suppl 1).
The Joint Commission. (2024). NPSG 07.04.01 and documentation requirements.