Documenting IV Site Assessments and IV Insertion (Nursing Guide)

Why This Matters

Regulatory bodies: Centers for Disease Control and Prevention (CDC), The Joint Commission, Infusion Nurses Society (INS), Centers for Medicare & Medicaid Services (CMS)

1. Guidelines for the Prevention of Intravascular Catheter-Related Infections — Centers for Disease Control and Prevention (CDC) (2024)
2. Infusion Therapy Standards of Practice — Infusion Nurses Society (INS) (2024)
3. Routine Versus Clinically Indicated Replacement of Peripheral Intravenous Catheters — Rickard CM et al. Lancet. 2012;380(9847):1066-1074 (2012)

Documenting IV Insertion

Documenting Site Assessment

Documenting IV Complications

When an IV site shows signs of a complication, document the findings, the clinical decision, and the actions taken.

Documenting IV Removal

Common Mistakes

Case Example

0800 - IV site assessment. 20G PIV, right cephalic vein, mid-forearm, inserted 04/10 at 2200 by night shift RN. VIP score 0 - site appears healthy. No redness, swelling, warmth, tenderness, or drainage. Transparent dressing is clean, dry, and intact, labeled with insertion date and time. Flushed with 3mL NS without resistance. Blood return obtained. Ceftriaxone 1g IVPB infusing over 30 minutes per order. Patient denies discomfort at site.

1500 - IV site assessment. 20G PIV, right cephalic vein, mid-forearm. VIP score 1. Patient reports mild tenderness on palpation 1cm proximal to the insertion site. No visible redness, swelling, or drainage. Dressing intact. Flushed without resistance. Blood return is sluggish but obtained. MD notified of VIP 1 finding - order to continue monitoring and reassess in 4 hours. Site marked with pen at the border of tenderness for comparison at the next assessment.

1845 - IV site reassessment. VIP score 2. Tenderness has extended 2cm proximal to the insertion site (beyond the pen marking from 1500). Mild redness is visible along the vein path. No swelling, no drainage, no palpable cord. Per VIP protocol and MD order, the decision is made to remove and relocate. IV ceftriaxone dose completed at 1830 - line flushed and capped prior to removal. Catheter removed intact - tip intact, measured 1.25 inches. Site: mild redness at the former insertion point. Pressure applied for 2 minutes, hemostasis achieved. Warm compress applied to the area of phlebitis per policy. Catheter dwell time: approximately 21 hours. Will monitor the former site for resolution.

1900 - New IV insertion. 20G x 1.25 inch catheter inserted into the left cephalic vein, mid-forearm. First attempt successful. Blood return obtained. Flushed with 3mL NS - no resistance, no pain, no swelling. Transparent dressing applied and labeled with date, time, and initials. Securement device in place. Patient tolerated the procedure without difficulty. Next ceftriaxone dose scheduled for 2200 - line patent and ready.

Pro Tips

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  Date and Time for Every Dressing and Label: When you place or change a dressing, document the date, time, and your initials directly on the dressing or label. This practice enables any nurse to quickly assess dwell time and dressing age without searching the chart. CDC guidelines recommend changing transparent dressings every 5-7 days and gauze dressings every 2 days unless they are soiled, loosened, or damp.
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  Document the Specific Vein, Not Just the Region: "Right cephalic vein, mid-forearm" provides specificity and utility. In contrast, "Right forearm" lacks precision, as it could refer to several veins within a large anatomical area. Specifying the vein is crucial for tracking site history, planning future access, and clearly communicating to the next nurse exactly where to look. If you used ultrasound guidance, document that as well.
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  Document Every Attempt, Including Failed Ones: Document each attempt on a separate line, noting the site, outcome, and reason for failure. For example, "Attempt 1: right basilic, antecubital - flash obtained but unable to advance catheter, removed" gives the next nurse useful information about this patient's vascular access. This documentation also protects you if the patient later complains about multiple sticks.
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  Use the VIP Scale for Every Site Assessment: The Visual Infusion Phlebitis (VIP) scale provides a standardized score (0-5) that any nurse can interpret. Even when the site appears healthy, document "VIP 0" to establish a trackable baseline. As the VIP score increases, the trajectory becomes visible in the chart, supporting clinical decision-making regarding when to remove and relocate the IV site.
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  Document the Site After Removal, Not Just the Removal: After pulling an IV, examine the site and describe your observations: "site without redness, swelling, or drainage; hemostasis achieved" or "1cm area of redness at former insertion point, no drainage." This final assessment closes the documentation loop and establishes a baseline for monitoring the old site during subsequent shifts.

Frequently Asked Questions

What should an IV insertion note include?

A complete IV insertion note includes seven elements: (1) date and time of insertion, (2) catheter gauge and length, (3) specific insertion site, including the vein name and anatomical location, (4) number of attempts, detailing failed attempts with sites and reasons, (5) blood return and flush confirmation, including saline volume and patency status, (6) dressing type and securement, along with labeling information, and (7) patient response to the procedure. If ultrasound guidance was used, document that as well.

How often should IV sites be assessed?

The Infusion Nurses Society (INS) recommends that nurses assess IV sites regularly, whenever an infusion starts, during the infusion, and upon completion. Most facilities require at least a once-per-shift assessment, while many have transitioned to assessments every 4 hours or every 6 hours for actively infusing lines. Always assess the site before administering any medication through the line. Use the VIP scale to standardize your assessment and document the score with each check.

When should a peripheral IV be replaced?

Current evidence and updated CDC guidance support replacing peripheral IVs based on clinical indications rather than at routine fixed intervals. The landmark Rickard et al. (2012) Lancet study demonstrated that clinically indicated replacement is not inferior to routine 72-hour replacement. Your site assessment serves as the decision-making tool: replace the IV when you observe signs of phlebitis (VIP score 2 or higher), infiltration, occlusion, dislodgement, or when the catheter is no longer needed. Some facilities still have time-based replacement policies; follow your institution's protocol, but understand that the evidence supports assessment-based replacement.

Related Guides

• Clinical charting hubDocumenting IV lines represents one of the core clinical charting categories.
• Nursing charting cheat sheetAccess all charting categories on one quick-reference page.
• SBAR handoff guideAssessing IV access status is crucial for any clinical SBAR handoff.
• Head-to-toe assessmentAssessing the IV site forms part of the comprehensive head-to-toe evaluation.
• Skin and wound documentationIV complications such as infiltration and phlebitis overlap with skin assessment documentation.
• What WDL means in nursingWhy "IV site WNL" says little on its own, and what WDL means instead.