Just as any other procedure or intervention, IV therapy must be documented.  This provides information about the care you give, the status of the patient, and assures quality and continuity of patient care.  Every facility has slightly different formats for you to follow, so be sure to be familiarize yourself with the format used where you work.  Be sure you are only using approved abbreviations, and that all documentation is clear and concise.  If you are using handwritten notes, your writing must be legible.  Patient information must remain private and confidential at all times.  

Always document any response a patient has to the procedure.  When starting IV therapy, note the following:

• The date and time the IV catheter was inserted
• The type, length and gauge of the catheter inserted
• The location the catheter was inserted
• The number and location of attempts made to insert the catheter
• The IV solution infused and any additives
• The rate of flow
• The condition of the IV site
• The name of the person who started the IV

Upon discontinuing the IV infusion, note the following:

• The amount of fluid infused prior to discontinuation
• The date and time of discontinuation
• Whether or not the catheter was intact upon removal
• The condition of the IV site
• The type of dressing that was applied
• The name of the person discontinuing the IV

Previous                                                                                                                          Next