We are in the process of updating the electronic medical record to capture all the required information per the new Standards regarding IV starts i.e. date, time, initials, attempts, pts reaction etc. This is not an issue with inpatients.
My question is how is this handled in outpatient areas? For example: pt having endo or colonoscopy when the IV will be in less than 2 hours? This area uses a paper progress flow sheet that is scanned into the electronic medical record later. The only thing that is captured on this flow sheet(as far as PIV) is the site and gauge. Some feel it would be quite time consuming to document everything listed in the standards for the short time the PIV will be in....
Thoughts???
Thank you!
Forum topic
Wed, 02/10/2016 - 14:44
#1
Documentation
I have seen one outpatient dept that used a pre-printed sticker with check boxes. They added this sticker to the paper and checked the appropriate boxes. As an expert on numerous legal cases, I can state that a signfiicant number of lawsuits occur in this outpatient setting when the catheter is only indwelling for a couple of hours. The lack of documentation in these cases have lead to many uncertainties about what was or was not done. At least document the presence of a blood return before each medication! INS SOP now contains numerous statements in multiple standards about the need for assessing blood return and this term is now defined in the glossary. This outpatient documentation is so critical to getting the complete picture in any legal case. Also for quality monitoring, competency validation, etc, etc. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thank you!