IV Site Assessment Documentation Example
IV site documentation records the device, location, appearance of the site, patency and any infusion, at the intervals required by policy.
Educational use & privacy
Educational documentation practice only. Use fictional or instructor-provided information. Do not enter real patient information or protected health information (PHI). Documentation requirements vary by organization, setting, role, policy, and applicable law.
Nursing Notes Privacy & SafetyContent status: Draft — not yet professionally reviewed.
Why it is structured this way
Specific site descriptions make it possible to notice changes between checks. "IV fine" does not show what was actually checked.
When this may be used
- At the intervals set by facility policy and when a concern arises.
- Documentation requirements, frequency and screens vary by organization, setting and EHR. Follow your program's and facility's policy.
Components
Device and location
What and where.
What belongs here
- Catheter gauge and site as documented at insertion
What does not belong
- Details you did not verify
Site appearance
Findings.
What belongs here
- Redness, swelling, temperature, tenderness, dressing condition
What does not belong
- "Looks OK"
Patency / infusion
Function.
What belongs here
- Flush result or infusing solution and rate per order
What does not belong
- Rates not verified
Actions and response
If a concern.
What belongs here
- Actions per policy and notification
What does not belong
- Invented treatment
Short fictional example
- Narrative
- 1200: 20-gauge IV right forearm. No redness or swelling. Dressing dry and intact. Normal saline infusing at 75 mL/h per order.
More detailed fictional example
- Focus
- IV site
- Data
- 1400: Left hand IV site swollen and cool to touch, 3 cm around insertion. Patient states "my hand feels tight."
- Action
- Infusion stopped and IV removed per unit policy; catheter tip intact. Left arm elevated on pillow. New IV started in right forearm by IV team at 1420.
- Response
- 1500: Left hand swelling decreased to 1 cm around former site. Patient states "it feels better."
Annotated example
Notes on the detailed example above:
3 cm around insertion
— Measured findings allow comparison.New IV started… by IV team
— Care by another team is attributed.
Common mistakes
- "IV patent" without saying how patency was checked.
- No description of the site.
- Not documenting follow-up of a problem site.
Good vs poor documentation
Weaker (fictional)
IV OK.
Stronger (fictional)
20-gauge IV right forearm; no redness or swelling; dressing dry and intact; flushed without resistance.
Why: Specific checks are documented.
Blank educational template
Narrative note: A chronological account in full sentences. Prompts only; nothing is prefilled.
- Time / context
- [Time of entry and reason for the note]
- What was observed or reported
- [Assessment findings actually obtained; patient statements in quotation marks]
- What was done
- [Nursing actions actually performed, and by whom if not you]
- Response and follow-up
- [Patient response, reassessment and any notification actually made]
Practice this format
- Practice Note Builder — write a practice note from a fictional scenario.
- Documentation practice questions
Related documentation guides
- Intake & output
- DAR notes
- Change in condition
- IV Flow Rate Calculator — Practice the mL/h math behind an infusion rate.
Sources
- ANA's Principles for Nursing Documentation (2010) — American Nurses Association.
- Nursing Fundamentals 2e — 2.5 Documentation — Open RN (Chippewa Valley Technical College).
- Fundamentals of Nursing — 14.5 Guidelines for Effective Documentation — OpenStax.
All examples on this page are original and fictional. Sources are used to check principles; they do not endorse Dosage Calcs. See Privacy & Safety.