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Report#: T101001
Patient, Name
Service Request Date:
Service Request Time:
Service Request Type:
Phone Consultation (PC)
Short Peripheral Catheter (SPC)
Subcutanious Line (SUBQ)
Extended Dwell Catheter (EDC)
Midline Catheter (MID)
PICC Line (PICC)
Port-A-Cath/Pass Port (PORT)
Port-A-Cath
Pass Port
Central Vascular Access Device (CVAD)
Subclavian Line (SUB)
Femoral Line (FEM)
Jugular Line (JUG)
Lab/Blood Draw (LAB)
Inservice/Course
Other...
Phone Consultation Request Reason:
Service Follow-Up
Procedure Questions
Type of Line Questions
Site Assessment Questions
Fluid/Medication Questions
Flushing Procedures/Standards
Troubleshooting Line
Troubleshooting Pump
CXR Results
Pharmacy Questions
Referred to Pharmacy
Other...
Troubleshooting Pump Reason:
Referred to Pharmacy
Pharmacy Requested Our Help
Line Not Reviewed Programing Instructions With Facility Staff
Discussed Training/Inservice With Facility Staff
Comments...
Short Peripheral Catheter Request Reason:
Start New PIV/SPC Placement
Re-Start PIV/SPC Placement
Fluids
Medications
Assessment/Troubleshoot PIV/SPC - Reported
Dressing Change PIV/SPC - Maintainence
Flush PIV/SPC - Maintainence
Removal PIV/SPC
Patient Pulled Mid/PICC - 48hr Replacement Policy
Other...
PIV/SPC Start/Re-Start Reason:
Occlusion - No Blood Return
Site Concerns/Complications
Site Rotation
Comments...
Fluid Type (1):
New Fluid
Existing Fluid
Comments...
Add Another Fluid...
Fluid Type (2):
New Fluid
Existing Fluid
Comments...
Add Another Fluid...
Fluid Type (3):
New Fluid
Existing Fluid
Comments...
Medication Type (1):
New Medication
Existing Medication
Comments...
Add Another Medication...
Medication Type (2):
New Medication
Existing Medication
Comments...
Add Another Medication...
Medication Type (3):
New Medication
Existing Medication
Comments...
PIV/SPC Assessment Reason:
Infiltration
Redness
Edema/Swelling
Pain at Insertion Site
Pain During Infusion
Possible Infection
Comments...
PIV/SPC Dressing Change Reason:
Non-Intact/Saturated Dressing
Bleeding/Leaking Under Dressing
Comments...
PIV/SPC Flush Reason:
Comments...
PIV/SPC Removal Reason:
LIP Order
Resident/Patient Request - LIP Order
Due To Assessment
Therapy Completed
Line Not Appropriate For Prescribed Therapy
Alternate Access
Comments...
PIV/SPC Patient Pulled Mid/PICC Reason:
Comments...
Subcutanious Line Request Reason:
Start New SUBQ Placement
Re-Start SUBQ Placement
Fluids
Medications
Assessment/Troubleshoot SUBQ - Reported
Dressing Change SUBQ - Maintainence
Flush SUBQ - Maintainence
Removal SUBQ
Other...
SUBQ Start/Re-Start Reason:
Occlusion - No Blood Return
Site Concerns/Complications
Site Rotation
Comments...
Fluid Type (1):
New Fluid
Existing Fluid
Comments...
Add Another Fluid...
Fluid Type (2):
New Fluid
Existing Fluid
Comments...
Add Another Fluid...
Fluid Type (3):
New Fluid
Existing Fluid
Comments...
Medication Type (1):
New Medication
Existing Medication
Comments...
Add Another Medication...
Medication Type (2):
New Medication
Existing Medication
Comments...
Add Another Medication...
Medication Type (3):
New Medication
Existing Medication
Comments...
SUBQ Assessment Reason:
Infiltration
Redness
Edema/Swelling
Pain at Insertion Site
Pain During Infusion
Possible Infection
Comments...
SUBQ Dressing Change Reason:
Non-Intact/Saturated Dressing
Bleeding/Leaking Under Dressing
Comments...
SUBQ Flush Reason:
Comments...
SUBQ Removal Reason:
LIP Order
Resident/Patient Request - LIP Order
Due To Assessment
Therapy Completed
Line Not Appropriate For Prescribed Therapy
Alternate Access
Comments...
Extended Dwell Catheter Request Reason:
Start New EDC Placement
Re-Start EDC Placement
Fluids
Medications
Assessment/Troubleshoot EDC - Reported
Dressing Change EDC - Maintainence
Flush EDC - Maintainence
Removal EDC
Patient Pulled Mid/PICC - 48hr Replacement Policy
Other...
EDC Start/Re-Start Reason:
Occlusion - No Blood Return
Site Concerns/Complications
Site Rotation
Comments...
Fluid Type (1):
New Fluid
Existing Fluid
Comments...
Add Another Fluid...
Fluid Type (2):
New Fluid
Existing Fluid
Comments...
Add Another Fluid...
Fluid Type (3):
New Fluid
Existing Fluid
Comments...
Medication Type (1):
New Medication
Existing Medication
Comments...
Add Another Medication...
Medication Type (2):
New Medication
Existing Medication
Comments...
Add Another Medication...
Medication Type (3):
New Medication
Existing Medication
Comments...
EDC Assessment Reason:
Infiltration
Redness
Edema/Swelling
Pain at Insertion Site
Pain During Infusion
Possible Infection
Comments...
EDC Dressing Change Reason:
Non-Intact/Saturated Dressing
Bleeding/Leaking Under Dressing
Comments...
EDC Flush Reason:
Comments...
EDC Removal Reason:
LIP Order
Resident/Patient Request - LIP Order
Due To Assessment
Therapy Completed
Line Not Appropriate For Prescribed Therapy
Alternate Access
Comments...
EDC Patient Pulled Mid/PICC Reason:
Comments...
Midline Catheter Request Reason:
Start New MID Placement
Re-Start MID Placement
Fluids
Medications
Assessment/Troubleshoot MID - Reported
Dressing Change MID - Maintainence
Flush & Cap Change MID - Maintainence
Removal MID
Patient Pulled Mid/PICC - 48hr Replacement Policy
Other...
MID Start/Re-Start Reason:
Occlusion - No Blood Return
Catheter Leaking
Site Concerns/Complications
Partially Out
Comments...
Fluid Type (1):
New Fluid
Existing Fluid
Comments...
Add Another Fluid...
Fluid Type (2):
New Fluid
Existing Fluid
Comments...
Add Another Fluid...
Fluid Type (3):
New Fluid
Existing Fluid
Comments...
Medication Type (1):
New Medication
Existing Medication
Comments...
Add Another Medication...
Medication Type (2):
New Medication
Existing Medication
Comments...
Add Another Medication...
Medication Type (3):
New Medication
Existing Medication
Comments...
MID Assessment Reason:
Infiltration
Catheter Leaking
Possible Occlusion
Redness
Edema/Swelling
Pain at Insertion Site
Pain During Infusion
Possible Infection
Comments...
MID Dressing Change Reason:
Non-Intact/Saturated Dressing
Bleeding/Leaking Under Dressing
Scheduled Care & Maintenance
Comments...
MID Flush & Cap Change - Maintenance Reason:
Comments...
MID Removal Reason:
LIP Order
Resident/Patient Request - LIP Order
Due To Assessment
Therapy Completed
Line Not Appropriate For Prescribed Therapy
Alternate Access
Comments...
MID Patient Pulled Mid/PICC Reason:
Comments...
PICC Line Request Reason:
Start New PICC Placement
Re-Start PICC Placement
Fluids
Medications
Assessment/Troubleshoot PICC - Reported
Dressing Change PICC - Maintainence
Flush & Cap Change PICC - Maintainence
Removal PICC
Patient Pulled MID/PICC - 48hr Replacement Policy
Other...
PICC Start/Re-Start Reason:
Occlusion - No Blood Return
Catheter Leaking
Site Concerns/Complications
Partially Out
Comments...
Fluid Type (1):
New Fluid
Existing Fluid
Comments...
Add Another Fluid...
Fluid Type (2):
New Fluid
Existing Fluid
Comments...
Add Another Fluid...
Fluid Type (3):
New Fluid
Existing Fluid
Comments...
Medication Type (1):
New Medication
Existing Medication
TPN
Comments...
Add Another Medication...
Medication Type (2):
New Medication
Existing Medication
Comments...
Add Another Medication...
Medication Type (3):
New Medication
Existing Medication
Comments...
PICC Occlusion - No Blood Return Reason:
Activase/Cathflow - Ordered
Activase/Cathflow - Notify IVNC When Medication Arrives
Activase/Cathflow - At Facility
Comments...
PICC Partially Out Reason:
Request CXR For Tip Location
Lower One-Third of SVC Near Cavoatrial Junction
Outside Optimal Tip Location
Comments...
PICC Assessment Reason:
Infiltration
Catheter Leaking
Possible Occlusion
Redness
Edema/Swelling
Pain at Insertion Site
Pain During Infusion
Possible Infection
Comments...
PICC Dressing Change Reason:
Non-Intact/Saturated Dressing
Bleeding/Leaking Under Dressing
Scheduled Care & Maintenance
Comments...
PICC Flush & Cap Change - Maintenance Reason:
Comments...
PICC Removal Reason:
LIP Order
Resident/Patient Request - LIP Order
Due To Assessment
Therapy Completed
Line Not Appropriate For Prescribed Therapy
Alternate Access
Unable To Clear Occlusion
Comments...
PICC Patient Pulled Mid/PICC Reason:
Comments...
PORT Request Reason:
Access Port-A-Cath/Pass Port
De-access Port-A-Cath/Pass Port
Access/De-access - Monthly Maintenance
Fluids
Medications
Assessment/Troubleshoot Port-A-Cath/Pass Port - Reported
Dressing Change Port-A-Cath/Pass Port - Maintainence
Flush & Cap Change Port-A-Cath/Pass Port - Maintainence
Occlusion Port-A-Cath/Pass Port - No Blood Return
Other...
Port-A-Cath/Pass Port Access Reason:
Comments...
Fluid Type (1):
New Fluid
Existing Fluid
Comments...
Add Another Fluid...
Fluid Type (2):
New Fluid
Existing Fluid
Comments...
Add Another Fluid...
Fluid Type (3):
New Fluid
Existing Fluid
Comments...
Medication Type (1):
New Medication
Existing Medication
TPN
Comments...
Add Another Medication...
Medication Type (2):
New Medication
Existing Medication
Comments...
Add Another Medication...
Medication Type (3):
New Medication
Existing Medication
Comments...
PORT De-access Reason:
LIP Order
Resident/Patient Request - LIP Order
Due To Assessment
Therapy Completed
Comments...
PORT Access/De-access Monthly Maintenance Reason:
Comments...
PORT Assessment Reason:
Occlusion - No Blood Return
Leaking at Needle Insertion Site
Site Concerns/Complications
Infiltration
Redness
Edema/Swelling
Pain at Insertion Site
Pain During Infusion
Possible Infection
Comments...
PORT Dressing Change Reason:
Non-Intact/Saturated Dressing
Bleeding/Leaking Under Dressing
Scheduled Care & Maintenance
Comments...
PORT Flush & Cap Change - Maintenance Reason:
Comments...
PORT Occlusion - No Blood Return Reason:
Activase/Cathflow - Ordered
Activase/Cathflow - Notify IVNC When Medication Arrives
Activase/Cathflow - At Facility
Comments...
Central Vascular Access Device Request Reason:
Fluids
Medications
Request Facility Notifies LIP/Physician CVAD
Assessment/Troubleshoot CVAD - Reported
Dressing Change CVAD - Maintainence
Flush & Cap Change CVAD - Maintainence
Occlusion CVAD - No Blood Return
Partially Out CVAD
Removal CVAD
Other...
Fluid Type (1):
New Fluid
Existing Fluid
Comments...
Add Another Fluid...
Fluid Type (2):
New Fluid
Existing Fluid
Comments...
Add Another Fluid...
Fluid Type (3):
New Fluid
Existing Fluid
Comments...
Medication Type (1):
New Medication
Existing Medication
TPN
Comments...
Add Another Medication...
Medication Type (2):
New Medication
Existing Medication
Comments...
Add Another Medication...
Medication Type (3):
New Medication
Existing Medication
Comments...
CVAD Request Facility Notifies LIP/Physician Reason:
Comments...
CVAD Assessment Reason:
Site Concerns/Complications
Infiltration
Catheter Leaking
Possible Occlusion
Redness
Edema/Swelling
Pain at Insertion Site
Pain During Infusion
Possible Infection
Comments...
CVAD Dressing Change Reason:
Non-Intact/Saturated Dressing
Bleeding/Leaking Under Dressing
Scheduled Care & Maintenance
Comments...
CVAD Flush & Cap Change - Maintenance Reason:
Comments...
CVAD Occlusion - No Blood Return Reason:
Activase/Cathflow - Ordered
Activase/Cathflow - Notify IVNC When Medication Arrives
Activase/Cathflow - At Facility
Comments...
CVAD Partially Out Reason:
Request CXR For Tip Location
Lower One-Third of SVC Near Cavoatrial Junction
Outside Optimal Tip Location
Request Call Back After CXR
Comments...
CVAD Removal Reason:
Cuffed Central Line (IVNC DOES NOT REMOVE)
Request Facility Notifies LIP/Physician for Removal
Non-Cuffed Central Line (ONLY)
LIP Order
Resident/Patient Request - LIP Order
Due To Assessment
Therapy Completed
Line Not Appropriate For Prescribed Therapy
Alternate Access
Unable To Clear Occlusion
Comments...
Subclavian Line Request Reason:
Fluids
Medications
Request Facility Notifies LIP/Physician SUB
Assessment/Troubleshoot SUB - Reported
Dressing Change SUB - Maintainence
Flush & Cap Change SUB - Maintainence
Occlusion SUB - No Blood Return
Partially Out SUB
Removal SUB
Other...
Fluid Type (1):
New Fluid
Existing Fluid
Comments...
Add Another Fluid...
Fluid Type (2):
New Fluid
Existing Fluid
Comments...
Add Another Fluid...
Fluid Type (3):
New Fluid
Existing Fluid
Comments...
Medication Type (1):
New Medication
Existing Medication
TPN
Comments...
Add Another Medication...
Medication Type (2):
New Medication
Existing Medication
Comments...
Add Another Medication...
Medication Type (3):
New Medication
Existing Medication
Comments...
SUB Request Facility Notifies LIP/Physician Reason:
Comments...
SUB Assessment Reason:
Site Concerns/Complications
Infiltration
Catheter Leaking
Possible Occlusion
Redness
Edema/Swelling
Pain at Insertion Site
Pain During Infusion
Possible Infection
Comments...
SUB Dressing Change Reason:
Non-Intact/Saturated Dressing
Bleeding/Leaking Under Dressing
Scheduled Care & Maintenance
Comments...
SUB Flush & Cap Change - Maintenance Reason:
Comments...
SUB Occlusion - No Blood Return Reason:
Activase/Cathflow - Ordered
Activase/Cathflow - Notify IVNC When Medication Arrives
Activase/Cathflow - At Facility
Comments...
SUB Partially Out Reason:
Request CXR For Tip Location
Lower One-Third of SVC Near Cavoatrial Junction
Outside Optimal Tip Location
Request Call Back After CXR
Comments...
SUB Removal Reason:
Non-Cuffed Central Line (ONLY)
Cuffed Central Line (IVNC DOES NOT REMOVE)
LIP Order
Resident/Patient Request - LIP Order
Due To Assessment
Therapy Completed
Line Not Appropriate For Prescribed Therapy
Alternate Access
Unable To Clear Occlusion
Request Facility Notifies LIP/Physician for Removal
Comments...
Femoral Line Request Reason:
Start New FEM Placement
Re-Start FEM Placement
Fluids
Medications
Request Facility Notifies LIP/Physician FEM
Assessment/Troubleshoot FEM - Reported
Dressing Change FEM - Maintainence
Flush & Cap Change FEM - Maintainence
Removal FEM
Patient Pulled MID/PICC - 48hr Replacement Policy
Other...
FEM Start/Re-Start Reason:
Occlusion - No Blood Return
Catheter Leaking
Site Concerns/Complications
Partially Out
Comments...
Fluid Type (1):
New Fluid
Existing Fluid
Comments...
Add Another Fluid...
Fluid Type (2):
New Fluid
Existing Fluid
Comments...
Add Another Fluid...
Fluid Type (3):
New Fluid
Existing Fluid
Comments...
Medication Type (1):
New Medication
Existing Medication
TPN
Comments...
Add Another Medication...
Medication Type (2):
New Medication
Existing Medication
Comments...
Add Another Medication...
Medication Type (3):
New Medication
Existing Medication
Comments...
FEM Occlusion - No Blood Return Reason:
Activase/Cathflow - Ordered
Activase/Cathflow - Notify IVNC When Medication Arrives
Activase/Cathflow - At Facility
Comments...
FEM Partially Out Reason:
Request CXR For Tip Location
Lower One-Third of SVC Near Cavoatrial Junction
Outside Optimal Tip Location
Request Call Back After CXR
Comments...
FEM Request Facility Notifies LIP/Physician Reason:
Comments...
FEM Assessment Reason:
Infiltration
Catheter Leaking
Possible Occlusion
Redness
Edema/Swelling
Pain at Insertion Site
Pain During Infusion
Possible Infection
Comments...
FEM Dressing Change Reason:
Non-Intact/Saturated Dressing
Bleeding/Leaking Under Dressing
Scheduled Care & Maintenance
Comments...
FEM Flush & Cap Change - Maintenance Reason:
Comments...
FEM Removal Reason:
LIP Order (MUST HAVE)
Resident/Patient Request - LIP Order (MUST HAVE)
Due To Assessment
Therapy Completed
Line Not Appropriate For Prescribed Therapy
Alternate Access
Unable To Clear Occlusion
Comments...
FEM Patient Pulled Mid/PICC Reason:
LIP To Review Options
TPN/Chemotherapy CANNOT Run Through (SPC)
Comments...
Jugular Line Request Reason:
Start New JUG Placement
Re-Start JUG Placement
Fluids
Medications
Has External Short Peripheral Catheter (SPC) Jugular Line (EJ)
Has Internal Central Jugular Line (IJ)
Has External Central Jugular Line (EJ)
Request Facility Notifies LIP/Physician JUG
Assessment/Troubleshoot JUG - Reported
Dressing Change JUG - Maintainence
Flush & Cap Change JUG - Maintainence
Removal JUG
Patient Pulled MID/PICC - 48hr Replacement Policy
Other...
JUG Start/Re-Start Reason:
Occlusion - No Blood Return
Catheter Leaking
Site Concerns/Complications
Partially Out
Comments...
Fluid Type (1):
New Fluid
Existing Fluid
Comments...
Add Another Fluid...
Fluid Type (2):
New Fluid
Existing Fluid
Comments...
Add Another Fluid...
Fluid Type (3):
New Fluid
Existing Fluid
Comments...
Medication Type (1):
New Medication
Existing Medication
TPN
Comments...
Add Another Medication...
Medication Type (2):
New Medication
Existing Medication
Comments...
Add Another Medication...
Medication Type (3):
New Medication
Existing Medication
Comments...
JUG Occlusion - No Blood Return Reason:
Activase/Cathflow - Ordered
Activase/Cathflow - Notify IVNC When Medication Arrives
Activase/Cathflow - At Facility
Comments...
JUG Partially Out Reason:
Request CXR For Tip Location
Lower One-Third of SVC Near Cavoatrial Junction
Outside Optimal Tip Location
Request Call Back After CXR
Comments...
JUG Request Facility Notifies LIP/Physician Reason:
Comments...
JUG Assessment Reason:
Infiltration
Catheter Leaking
Possible Occlusion
Redness
Edema/Swelling
Pain at Insertion Site
Pain During Infusion
Possible Infection
Comments...
JUG Dressing Change Reason:
Non-Intact/Saturated Dressing
Bleeding/Leaking Under Dressing
Scheduled Care & Maintenance
Comments...
JUG Flush & Cap Change - Maintenance Reason:
Comments...
JUG Removal Reason:
LIP Order (MUST HAVE)
Resident/Patient Request - LIP Order (MUST HAVE)
Due To Assessment
Therapy Completed
Line Not Appropriate For Prescribed Therapy
Alternate Access
Unable To Clear Occlusion
Comments...
JUG Patient Pulled Mid/PICC Reason:
LIP To Review Options
TPN/Chemotherapy CANNOT Run Through (SPC)
Comments...
Lab/Blood Draw Request Reason:
Facility Staff Requesting Our Services
Reviewed Our Terms For Blood Draw Only
Did NOT Review Our Terms For Blood Draw Only
Other...
Comments...
Lab/Blood Draw Obtained By:
Central Line
Port-A-Cath
Venipuncture
Lab/Blood Draw Obtained For:
Medication Peak
Medication Through
Other
Comments...
Reviewed Our Terms For Blood Draw Only:
Facility nursing staff is responsible for appropriate color tubes, labeling, storage, and delivery of all specimens as indicated by facility’s lab provider policies. Prior to IV Nurses' arrival, Facility Nurse has obtained approval for IV Nurse to draw labs with the understanding, facility will be charged for an IV Nurse Visit. I.V. Nurse Consultants is responsible solely for obtaining specimen and providing it to facility staff Nurse. If lab is unable to be drawn it will be referred back to the patient’s primary physician.
Facility nursing staff understands there is no cost for blood draws while placing lines during other procedures.
Comments...
Inservice/Course Request Reason:
Inservice
Course
Other...
Comments...
Inservices:
Central Line Dressing Changes
Catheter Occlusion Management
Midline/PICC Care & Maintenance Review
Midline/PICC Removal Review
Port Access - Basic Overview
Prevention of Patient Pulling Lines
Subcutaneous/Hypodermoclysis Review
Total Parenteral Nutrition (TPN)
Infection Control & Possible Complications
Comments...
Courses:
Basic IV Therapy (8hrs)
Advanced IV Therapy (8hrs)
Basic/Advanced IV Therapy (16hrs)
IV Refresher Course (4hrs)
Comments...
Verified Appropriate Order Has Been Obtained?
Yes
No
Comments...
Requested Face Sheet & Order To Be Available?
Yes
No
Comments...
Resident/Patient MEDICAL HISTORY Reported?
Yes
No
Comments...
On Blood Thinners?
Yes
No
Comments...
INR Results (Line Placement Range 1.0-2.6):
PTT Results (Line Placement Range Platelets >30k):
Lab Not Available
Type Of Blood Thinners:
Past CVA?
Yes
No
Comments...
Side Weakness?
Yes
Left
Right
No
Comments...
Arm Contractures?
Yes
Left
Right
No
Comments...
Has Shunt?
Yes
Left
Right
No
Comments...
On Dialysis?
Yes
No
Comments...
Obtained Nephrologist's Order Prior To Placement?
Yes
No
Comments...
Had Mastectomy?
Yes
Left
Right
No
Comments...
Axillary Lymphadenectomy?
Yes
Left
Right
No
Comments...
Obtained Surgical Physician's Order Prior To Placement?
Yes
No
Comments...
Other Related Medical History?
Yes
No
Discussed S/L x 48hr Prior To PICC Placement?
Yes
No
N/A
Other
Obtain CXR Order Post PICC Placement?
Yes
No
N/A
Other
Has line been pulled?
By Patient
By Staff
Unknown
Other
Additional Pre-Service Comments:
Confidental Pre-Service Comments:
Name of IVRN Activated:
IVRN Activation Date/Time: