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.

By Miranda, Nursing Student (BSN candidate)

This guide is currently pending review by a licensed clinical nurse.

Last updated: April 11, 2026

Documenting IV Site Assessments and IV Insertion (Nursing Guide)

Quick Reference

IV documentation has 3 phases: insertion, ongoing site checks, and removal. Each phase has its own required elements.

Insertion note - 7 required elements: date/time, gauge, site (specific vein), number of attempts, flush/patency, dressing applied, and patient response
Conduct a site assessment every shift (or per facility policy) to check for redness, swelling, warmth, pain, drainage, and dressing integrity using the VIP scale.
For complications, document the type (infiltration, phlebitis, occlusion, dislodgement), findings, actions taken, and provider notification.
Removal note - include date/time, reason for removal, site condition after removal, dwell time, and whether a new IV was placed.
Record the date and time for every dressing and label. CDC guidelines recommend changing transparent dressings every 5-7 days and gauze dressings every 2 days unless soiled or loose.
Document the specific vein, not just the region. For example, "right cephalic vein, mid-forearm" is defensible; "right arm" is not.

Your first IV insertion went fine - you got it on the second attempt, the flush was smooth, the patient barely flinched. Now you're sitting at the computer and you realize you're not sure what a complete insertion note actually looks like. Do you chart the gauge? The number of attempts? The exact vein? What about the patient who already had an IV when you took over - what does a site assessment note include when you didn't place the line? This page covers every phase of IV documentation so you know exactly what to write whether you're starting a new line, checking an existing one, or pulling one that's gone bad.

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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)

Catheter-related bloodstream infections (CRBSIs) rank among the most preventable hospital-acquired infections, and documenting is a key element of the prevention bundle. The CDC's guidelines for preventing intravascular catheter-related infections emphasize standardized site assessment, timely dressing changes, and documenting catheter necessity as core prevention strategies. The Infusion Nurses Society's Standards of Practice (2024 edition) specify documentation requirements for every phase of the IV lifecycle: insertion, site assessment, dressing changes, complications, and removal. CMS tracks CLABSI (central line-associated bloodstream infections) as a hospital-acquired condition affecting reimbursement. While this primarily applies to central lines, the discipline of documentation also extends to peripheral IVs. A landmark Lancet study (Rickard et al., 2012) found that routine replacement of peripheral IVs at fixed intervals (such as the traditional 72-96 hours) was not clinically superior to replacement only when clinically indicated, shifting many institutions toward assessment-based replacement policies. Now, your site assessment documentation triggers IV replacement decisions, making each assessment entry clinically and legally consequential.

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

Documenting IV Insertion

Every IV insertion requires documentation that includes seven elements. These apply whether you place a peripheral IV in an emergency or start a scheduled line on a stable patient. 1. Date and time - document the exact time the catheter was inserted, not when you charted the note. 2. Catheter gauge and length - specify as "20G x 1.25 inch" or "18G x 1.16 inch." The gauge affects infusion rates and compatibility with blood products or contrast media. 3. Insertion site - identify the specific vein, not just the anatomical region. "Right cephalic vein, mid-forearm" tells the next nurse exactly where to look, while "Right forearm" does not. If you used ultrasound guidance, document that as well. 4. Number of attempts - document every attempt, including failed ones, along with the site and reason for failure. For example, "First attempt: left basilic vein, antecubital - unable to advance catheter, removed. Second attempt: right cephalic vein, mid-forearm - successful." Patients have a right to know how many times they were stuck, and some facilities use attempt data for competency tracking. 5. Blood return and flush - confirm placement in your documentation. For instance, "Blood return obtained. Flushed with 3mL normal saline - flushes without resistance, no pain or swelling at site." 6. Dressing and securement - specify the type of dressing (transparent/Tegaderm, gauze and tape), whether a securement device was used, and that the dressing was labeled with the date, time, and your initials. 7. Patient response - describe how the patient tolerated the procedure. Use phrases like "Patient tolerated procedure without difficulty" or "Patient reported moderate pain during insertion; resolved after catheter secured."

Documenting Site Assessment

Perform IV site assessments at least every shift and before, during, and after each infusion. Your assessment documents the current condition of the insertion site and the catheter's function. If your facility has adopted it, use the Visual Infusion Phlebitis (VIP) scale; this standardized scoring system provides a common language for nurses to grade site findings. A site assessment entry should include the date and time of assessment, VIP score (0-5), specific findings at the site (presence or absence of redness, swelling, warmth, tenderness, palpable cord, purulent drainage), dressing condition (clean, dry, intact, or soiled/loose/needs replacement), catheter function (flushes without resistance, blood return present or absent, infusion running at the correct rate), and any actions taken. Example of a routine site assessment with no complications: "0800 - IV site assessment. 20G PIV, right cephalic vein, mid-forearm, inserted 04/09. VIP score 0 - IV site appears healthy. No redness, swelling, warmth, tenderness, or drainage. Dressing clean, dry, and intact with date label visible. Flushed with 3mL NS without resistance. Blood return obtained. NS infusing at 125mL/hr per order. No patient complaints." Example of a site with early changes: "1500 - IV site assessment. 20G PIV, right cephalic vein, mid-forearm, inserted 04/09. VIP score 1 - possible first sign of phlebitis. Slight tenderness reported on palpation proximal to the insertion site. No visible redness, swelling, or drainage. Dressing intact. Flushed without resistance. Will monitor closely and reassess in 4 hours. MD notified of VIP 1 finding."

Documenting IV Complications

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

Infiltration

Infiltration occurs when IV fluid leaks into the surrounding tissue. Signs include swelling, coolness, pallor, and pain or tightness at the site. The infiltration may be graded on a 0-4 scale based on the degree of swelling and skin changes. Documentation should include: the time you identified the infiltration, the specific signs observed (measure the swelling if possible - "2cm area of swelling circumferentially around insertion site"), the grade if your facility uses a grading scale, that you stopped the infusion and removed the catheter, the condition of the site after removal, any interventions (elevation, warm or cold compress per policy), and MD notification. Example: "1200 - Patient reports tightness at IV site. Assessment reveals 2cm area of edema surrounding insertion site, skin cool and pale compared to opposite extremity. No erythema or streaking. Infiltration grade 2. IV infusion stopped. Catheter removed intact - tip intact. Site elevated. Warm compress applied per policy. MD notified. New IV access to be obtained in left upper extremity."

Phlebitis

Phlebitis is inflammation of the vein. The VIP scale grades phlebitis from 0 (no symptoms) to 5 (advanced-stage thrombophlebitis). Signs progress from tenderness and redness at the site to palpable cord, purulent drainage, and fever. VIP 0: No symptoms - observe. VIP 1: Slight pain near site or slight redness - observe and reassess. VIP 2: Two of: pain, redness, swelling - consider relocating catheter. VIP 3: All of: pain along cannula path, redness, palpable venous cord - remove catheter and relocate. VIP 4: All of VIP 3 plus palpable cord >1 inch, purulent drainage - remove catheter, consider culture, notify MD. VIP 5: All of VIP 4 plus fever - remove catheter, culture tip, blood cultures, notify MD immediately. Document the VIP score and the specific findings that support the score. If you remove the catheter, document that the tip was intact and whether you sent the tip for culture.

Occlusion

An occluded IV will not flush or will trigger a pump occlusion alarm. Before documenting the occlusion as a complication, troubleshoot: check for kinks in the tubing, verify the clamp is open, reposition the patient's extremity, and attempt a gentle flush. Document your troubleshooting steps and the outcome. If the line cannot be restored, document removal and the plan for new access. Example: "1630 - IV pump alarming for upstream occlusion. Tubing checked - no kinks. Clamp verified open. Patient repositioned arm - alarm persists. Attempted gentle flush with 3mL NS - resistance encountered, unable to flush. Catheter removed intact. Site without redness, swelling, or drainage. New 20G PIV placed in left hand dorsal metacarpal vein - see insertion note."

Dislodgement

A dislodged IV has partially or completely come out of the vein. This can happen during patient movement, transfers, or if the securement device fails. Document how you discovered the dislodgement, the condition of the site, whether any portion of the catheter tip is missing (inspect the catheter carefully), and the plan for replacement. Example: "1045 - Patient found with IV catheter partially dislodged from right forearm site. Dressing loosened, hub visible outside skin. Infusion stopped. Catheter removed - tip intact, measured at expected length. Site without signs of infiltration or phlebitis. Pressure applied x2 minutes, hemostasis achieved. New IV access obtained - see insertion note."

Documenting IV Removal

Every IV removal requires its own documentation entry with 5 elements: 1. Date and time of removal. 2. Reason for removal - "IV therapy complete," "phlebitis - VIP 3," "infiltration," "routine replacement per policy," "patient request," or "catheter dislodged." 3. Catheter integrity - inspect the catheter tip after removal and document that it is intact. If the tip appears damaged or a portion may have broken off, this is a medical emergency - notify the provider immediately and document the concern. "Catheter removed intact" or "catheter tip appears intact, measured 1.25 inches consistent with original length." 4. Site condition after removal - describe what the site looks like after you remove the catheter and apply pressure. "Site without redness, swelling, or drainage. Hemostasis achieved with 2 minutes of direct pressure. Band-Aid applied." Or: "Site with 1cm area of redness and tenderness - consistent with VIP 2 findings prior to removal. No drainage. Will monitor." 5. Dwell time and replacement - how long was the catheter in place? If a new IV was started, reference the new insertion note. "Catheter dwell time: 72 hours. New 20G PIV inserted in left cephalic vein - see insertion note 1900." Dwell time tracking supports your facility's infection prevention data and helps the next nurse understand the IV history.

Common Mistakes

"IV site WNL" with no specific findings

Weak: IV site WNL. Continue to monitor.

Strong: 0800 - IV site assessment. 20G PIV, right cephalic vein, mid-forearm, inserted 04/09. VIP 0. No redness, swelling, warmth, tenderness, or drainage. Dressing clean, dry, intact. Flushed with 3mL NS, no resistance. NS at 125mL/hr infusing. No complaints.

"WNL" (within normal limits) tells a reviewer nothing about what you actually assessed. Did you look at the site? Did you flush the line? Did you check the dressing? The strong example demonstrates that a specific, systematic assessment was performed.

No site assessment for 12+ hours

Weak: IV noted in place at start of shift. No further documentation until removal at 1800.

Strong: Site assessed at the start of my shift (0700) and every 4-6 hours thereafter, with each assessment documented as its own entry including VIP score, findings, and catheter function.

INS standards require regular site assessments. A 12-hour gap between entries indicates no documented evidence of anyone examining the IV site for half a day. If the patient develops phlebitis or an infection, the documentation gap will be challenging to defend.

Missing insertion note entirely

Weak: IV in place, right forearm. Antibiotics infusing.

Strong: Complete insertion note with date/time, gauge, specific vein, number of attempts, blood return/flush confirmation, dressing type and label, and patient response.

If you placed the IV, you need an insertion note. If you inherited the IV from a previous shift and there is no insertion note in the chart, document what you can observe and note the gap: "20G PIV in place right forearm per previous shift. Insertion note not found in chart. Site assessed: VIP 0, dressing dated 04/09 at 1400."

Number of Attempts Not Documented

Weak: IV placed in right hand after some difficulty.

Strong: First attempt: right cephalic vein, forearm - vein blew on advancement, catheter removed. Site: small ecchymosis, pressure applied. Second attempt: right dorsal metacarpal vein - successful. Blood return obtained, flushed without resistance.

Patients have the right to know how many times they were stuck. Many facilities track attempt data for competency purposes. Vague phrases like "some difficulty" do not protect you or the patient. Document each attempt with the site, outcome, and reason for failure.

Generic "no complications" without supporting assessment

Weak: IV running, no complications.

Strong: 1400 - IV site assessment. 18G PIV, left AC, inserted 04/10. VIP 0. No redness, swelling, warmth, or tenderness. Dressing intact. Running D5 0.45NS + 20 KCl at 100mL/hr per order. Blood return obtained. Patient denies pain at site.

The phrase "no complications" lacks supporting assessment details. Without specific findings, the evaluation remains unclear. The strong example provides detailed assessment findings that substantiate the conclusion of no complications.

Mr. DelgadoAge 52 — Community-acquired pneumonia; IV ceftrioxone ordered

fictional patient

Scenario

You are the day shift nurse on a medical floor. Mr. Delgado was admitted yesterday for pneumonia and is receiving IV antibiotics. He has a 20G PIV in his right forearm placed by the night shift. Over the course of your shift, the IV site progresses from healthy to early phlebitis, requiring removal and replacement. Here are the key documentation entries showing the lifecycle of IV management.

Chart Entry

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.

Annotations

0800 - Baseline documented thoroughly:: The first assessment of the shift establishes the baseline: VIP 0, specific findings documented, and catheter function confirmed. This serves as the comparison point for all subsequent assessments.
1500 - Early change caught and marked:: VIP 1 is subtle - just tenderness without visible changes. The nurse documented the finding, notified the MD, and marked the border with pen for objective comparison later. This demonstrates proactive site monitoring.
1845 - Progression documented with clinical reasoning:: The nurse documents that findings progressed beyond the previous pen marking, justifies the removal decision with VIP score and MD order, and includes catheter integrity check, dwell time, and site care after removal.
1900 - New insertion note is complete:: All 7 insertion elements are present: date/time, gauge, specific vein, attempt count, blood return/flush, dressing/securement, and patient response. The entry links to the clinical context (next antibiotic dose) so the oncoming shift understands why a new line was placed.

Pro Tips

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.
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.
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" provides the next clinician with valuable information about this patient's vascular access. This documentation also protects you if the patient later complains about multiple sticks.
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.
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.

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