Central Line Template - DOC by sgk24546

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									   Central Venous Catheter
   Placement Procedure Note
      Date ________ Time ______

   □ New central venous catheter □ Guide wire exchange
Indications:   □   Hemodynamic monitor/instability                   Diagnosis: ____________________
               □   Medications require central venous access                     ___________________
               □   Inability to get peripheral access                            ___________________
               □   Acute short term hemodialysis/apheresis
               □   Infusion of > 3 incompatible continuous infusions
                     or 2 continuous infusions plus blood product

   Consent:                                             □ Sterile barriers: Sterile gloves, sterile gown,
   □ Informed consent was obtained from                 cap, mask, large sterile drape
   _______________________________                      □ Anesthetized site with lidocaine
   □ This procedure was done emergently                 □ Patient in Trendelenberg position
                                                        □ Modified Seldinger technique
   Insertion Site: □ Right □ Left                       □ New sterile gloves used to insert catheter during
   □ Subclavian                                         guidewire exchange
   □ Jugular                                            □ Sterile field maintained throughout procedure
   □ Femoral (indication required)                      □ Emergent line placement (consider
   ____________________________                         replacement in 24 hours)
   □ Other sites where placement attempted
   ___________________                                  Following Procedure:
   ____________________________                         □ Blood was aspirated from all lumens, ports
                                                        were flushed, and a sterile dressing was placed
   Type of catheter:                                    □ Chest x-ray was ordered for Subclavian and
   □ Non-tunneled □1 □2 □3 □4 lumens                    Internal Jugular attempt(s)
   □ Introducer          □ Hypothermia CVC
   □ Pulmonary artery    □ Antiseptic impregnated       □ Patient tolerated without immediate complications
   □ Dialysis catheter   □ Other__________              □ Patient experienced complications:
   □ Transvenous pacer                                         □ Bleeding      □ EBL _________
                                                               □ Hematoma
   Skin Prep:                                                  □ Pneumothorax
   □ Chlorhexidine (preferred)                                 □ Arterial puncture
   □ Povidone iodine (dialysis/aphresis catheters)             □ Air embolism
                                                               □ Neurologic changes
   Ultrasound guided:                                          □ Other __________________________
   □ Yes □ No                                                  _________________________________
                                                               _________________________________
   Conditions:
      Additional comments: ____________________________________________
      ________________________________________________________________

   □ Time spent performing the procedure is not documented in a separate patient care report in the
   patient’s medical record.

   Performed by (check one)                             Attending physician present during critical
   □ Attending □ Resident/Fellow □ NP         □PA       portion(s) of procedure
                                                        Attending Signature _____________________
   Signature _______________________________
                                                        Print name________________ PIC_________
   Print name________________ PIC___________


                                                                                       05/23/05

								
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