Documentation in the Health Record for Vascular Access Policy

1. Policy Statement

It is the policy of this organization that every vascular access event—from device insertion through ongoing assessment, maintenance, medication administration, and device removal—shall be accurately, completely, and timely documented in the patient’s electronic health record (EHR) using standardized formats that enable continuity of care, legal defensibility, quality improvement data extraction, and regulatory compliance. The health record serves as the legal and clinical proof of care rendered. Any vascular access assessment, intervention, or clinical decision that is not documented is legally considered not to have occurred.

2. Purpose

This policy exists to:

• Establish comprehensive documentation as a non-negotiable standard of vascular access practice, recognizing that the health record is the primary legal defense against claims of negligence and the primary data source for quality improvement.
• Define the minimum data elements that must be captured for every vascular access insertion, ongoing assessment, maintenance activity, medication administration, and device removal.
• Standardize the documentation format to ensure consistency across clinicians, units, and care settings, enabling meaningful data aggregation and comparison.
• Mandate the use of EHR clinical decision support (CDS) tools—such as hard stops for line necessity and automated alerts for dressing changes—to improve compliance with vascular access safety protocols.
• Ensure that documentation supports seamless continuity of care across shifts, transfers, and care transitions.

3. Scope

This policy applies to:

• All licensed clinical personnel who document vascular access care in the patient’s health record, including RNs, LPN/LVNs, APRNs, Physicians, PAs, Vascular Access Specialists, and any other authorized documenters.
• All vascular access device types: peripheral IV catheters, midline catheters, PICCs, tunneled and non-tunneled central venous catheters, implanted ports, and intraosseous devices.
• All vascular access activities, including: insertion, site assessment, dressing changes, catheter flushing and locking, blood specimen collection, medication and infusion administration, complication identification and management, patient education, line necessity review, and device removal.
• All clinical settings within the organization.
• The Health Information Technology (HIT) department insofar as it is responsible for the design, maintenance, and optimization of EHR vascular access documentation templates and clinical decision support tools.

4. Policy Requirements

4.1 General Documentation Standards

4.1.1 Accuracy. All documentation shall be factual, objective, and based on the clinician’s direct observation, assessment findings, and clinical judgment. Subjective language, speculation, and unsupported conclusions shall be avoided. The clinician shall document what was seen, heard, done, and communicated.

4.1.2 Timeliness. Documentation shall be completed as close to the time of the event as possible. The following timeliness standards apply:

• Routine site assessments and maintenance activities: documented within one (1) hour of the activity.
• Insertion and removal procedures: documented immediately upon completion, and no later than the end of the clinician’s shift.
• Urgent or emergent events (e.g., catheter-related bloodstream infection, air embolism, extravasation, accidental dislodgment): documented as soon as the patient is stabilized and safe, and no later than two (2) hours after the event.
• Late entries: If documentation cannot be completed within the required timeframe, a late entry shall be made with the actual date and time of the entry, the date and time of the event being documented, and the reason for the delay.

4.1.3 Standardized Format. The organization shall maintain standardized EHR documentation templates for all vascular access activities. Clinicians shall use these templates to ensure that all required data elements are captured in discrete, reportable fields (rather than unstructured free text alone) to enable data extraction for quality improvement and surveillance.

4.1.4 Prohibition on Pre-Documentation. Clinicians shall not document an assessment or intervention before it has been performed. Pre-documentation of future care activities is prohibited.

4.1.5 Corrections and Amendments. Errors in the health record shall be corrected in accordance with the organization’s Health Information Management policy. Under no circumstances shall documentation be deleted, altered, or backdated to conceal an error or omission.

4.2 Insertion Documentation

4.2.1 Every vascular access device insertion shall be documented with the following minimum data elements:

• Date and time of the procedure.
• Name and credentials of the inserting clinician.
• Type of vascular access device inserted (e.g., 20G short peripheral catheter, 5Fr dual-lumen PICC, 7Fr triple-lumen non-tunneled CVC).
• Manufacturer and lot number of the device (if applicable and available).
• Anatomical insertion site (specific location, not just “right arm”) and laterality (right/left).
• Vein used for access (e.g., right basilic vein, left cephalic vein, right internal jugular vein).
• Number of insertion attempts, including any failed attempts and the sites attempted.
• Visualization or guidance technologies used during insertion (e.g., ultrasound, near-infrared light, fluoroscopy, ECG-guided tip confirmation).
• Catheter length: total catheter length, length inserted (internal), and external length from the insertion site to the hub.
• For central venous access devices: catheter tip location and the method used to confirm tip position (e.g., chest X-ray, intracavitary ECG, fluoroscopy).
• Skin antiseptic agent used and application method.
• Local anesthetic used (if any), agent, and dose.
• Type of dressing and securement device applied.
• Patient tolerance of the procedure: pain level, anxiety, and any adverse events during the procedure.
• Post-insertion assessment findings: site appearance, patency (flush and blood return), and distal circulation.
• Presence and quality of informed consent documentation (for procedures requiring formal written consent).

4.3 Ongoing Assessment and Maintenance Documentation

4.3.1 Site Condition. Each site assessment shall document the visual and palpable findings, including but not limited to: presence or absence of erythema, edema, induration, warmth, tenderness, drainage (type and amount), ecchymosis, and skin integrity around the dressing margins. Findings shall be described using objective, measurable terms (e.g., “2 cm area of erythema surrounding the insertion site”) and, where applicable, graded using the organization’s adopted phlebitis or infiltration scale.

4.3.2 Device Patency. Each assessment shall document: confirmation of blood return (present, absent, or sluggish) and the ease or difficulty of flushing (flushed without resistance, flushed with moderate resistance, unable to flush). Any change from the previous assessment shall trigger immediate clinical evaluation and documentation of the findings and interventions.

4.3.3 Dressing and Securement. Documentation shall include: dressing type, integrity status (intact/non-intact), cleanliness (clean/soiled), adherence (adherent/lifting), the date of the current dressing application, and the date of the next scheduled change. Any unscheduled dressing change shall include the reason for the change.

4.3.4 Line Necessity. For all central vascular access devices, the responsible clinician shall document daily whether the central line continues to be clinically necessary. The documentation shall include the specific clinical indication supporting continued use (e.g., “vesicant chemotherapy requiring central access,” “no peripheral access obtainable,” “TPN administration”). If the device is no longer necessary, the clinician shall document initiation of the removal process.

4.4 Medication and Infusion Administration Documentation

4.4.1 Every medication or infusion administered through a vascular access device shall be documented with: the drug name, dose, concentration, and diluent (if applicable); the route (specific lumen if multi-lumen device); the rate of infusion and the method of administration (gravity, electronic infusion pump, syringe pump); the start and stop times of the infusion; use of Dose Error Reduction System (DERS) or smart pump drug library (documented as “administered within DERS” or, if overridden, the reason for override documented); barcode medication administration (BCMA) scanning compliance (scanned successfully, or reason for bypass); and any patient observations during and after administration, including adverse reactions, signs of extravasation, or infusion-related symptoms.

4.4.2 Override and Alert Documentation. Any smart pump DERS override or BCMA bypass shall be documented with the specific clinical rationale for the override. Patterns of overrides shall be reported to the Medication Safety Committee per the Quality Improvement Policy (POL-008).

4.5 Removal Documentation

4.5.1 Every vascular access device removal shall be documented with: the date and time of removal; the name and credentials of the clinician performing the removal; the reason for removal (therapy complete, complication, patient request, line no longer necessary, device malfunction); the catheter length upon removal, compared to the documented insertion length, to verify that the entire catheter was removed intact; visual inspection findings of the catheter tip (intact, damaged, or any concern for retained fragment); the appearance of the insertion site post-removal (presence or absence of bleeding, drainage, erythema); post-removal site care applied (e.g., occlusive dressing, hemostatic agent); and patient tolerance of the procedure.

4.5.2 If the catheter tip is not intact upon removal or if there is any suspicion of a retained catheter fragment, the clinician shall immediately notify the physician, document the findings, and initiate the organization’s Retained Catheter Fragment Protocol.

4.6 Electronic Health Record Integration and Clinical Decision Support

4.6.1 The organization shall implement and maintain EHR clinical decision support (CDS) tools that enhance vascular access safety and compliance, including: automated alerts for overdue site assessments based on the assessment intervals defined in organizational policy; automated alerts for overdue dressing changes; daily line necessity reminders or “hard stops” that require completion before other CVAD-related documentation can be finalized; best practice alerts (BPAs) triggered by clinical conditions that affect vascular access management (e.g., alert when a vesicant medication is ordered to confirm appropriate access type); and insertion order sets that pre-populate required documentation fields and guide evidence-based device selection.

4.6.2 The VAGC shall collaborate with HIT to ensure that documentation templates are optimized for clinician workflow efficiency while capturing all required discrete data elements, and shall conduct at minimum an annual review of EHR vascular access templates for accuracy, completeness, and usability.

4.6.3 Alert Fatigue Mitigation. CDS alerts shall be designed and maintained to minimize alert fatigue. The VAGC and HIT shall review alert firing rates, override rates, and clinician feedback at minimum semi-annually and shall modify alert logic to suppress clinically insignificant alerts while preserving high-priority safety alerts.

5. Compliance

5.1 Monitoring. Compliance shall be monitored through quarterly chart audits assessing documentation completeness for insertions, assessments, maintenance, medication administration, and removals (using a standardized audit tool); real-time EHR compliance reports tracking line necessity documentation completion rates, dressing change documentation timeliness, and BCMA scan rates; review of late entry frequency and patterns; and annual review of EHR template utilization and CDS alert effectiveness.

5.2 Key Performance Indicators.

• Insertion documentation completeness rate (all required data elements present) (target: ≥95%).
• Site assessment documentation timeliness rate (documented within one hour) (target: ≥90%).
• Daily CVAD line necessity documentation rate (target: 100%).
• BCMA scanning compliance rate for IV medications (target: ≥95%).
• Smart pump DERS utilization rate (target: ≥95%).
• Removal documentation completeness rate (target: ≥95%).

5.3 Enforcement. Documentation deficiencies identified through audits shall be addressed through individual clinician feedback and coaching. Recurrent or systemic documentation failures shall be escalated through the progressive corrective action process. Documentation deficiencies identified as contributing factors in adverse events shall be addressed through the root cause analysis and quality improvement process.

6. Exceptions

6.1 In emergent, life-threatening situations where documentation must be deferred to prioritize patient care, the clinician shall complete all required documentation as soon as the patient is stabilized, and no later than the end of the clinician’s shift. The documentation shall include a notation that the entry was deferred due to an emergent clinical situation.

6.2 Requests for exceptions to specific documentation data element requirements (e.g., catheter lot number not available for an emergently placed device) shall be documented with the reason the element could not be captured.

7. Related Documents

• SOP-VA-120: Vascular Access Insertion Documentation Procedure
• SOP-VA-121: Vascular Access Site Assessment Documentation Procedure
• SOP-VA-122: Vascular Access Device Removal Documentation Procedure
• SOP-VA-123: EHR Vascular Access Template Maintenance and Review Procedure
• SOP-VA-124: Retained Catheter Fragment Protocol
• POL-003: Evidence-Based Selection and Clinical Monitoring Standards
• POL-008: Quality Improvement in Vascular Access
• POL-009: Patient Education in Infusion Therapy
• POL-011: Informed Consent for Vascular Access Procedures
• Vascular Access Documentation Audit Tool
• Vascular Access EHR Template Specifications
• Organizational Health Information Management Policy
• Organizational BCMA Policy
• Joint Commission Record of Care Standards (RC.01.01.01 et seq.)
• CMS Conditions of Participation: Medical Record Services

8. Revision History