We are looking into how to document specific IV site with computer documentation. We feel we would like to be able to determine exact site when we have to review a chart. Does anyone out there have suggestions for specific site documentation on the computer as we already know we cannot add a diagram. Any suggestions would be very helpful. I know this has been addresses before but I cannot find anything specific. Thanks. Feel free to e-mail me if you have any charts, etc. and Thanks again.
Marjorie Ashley, RN, CRNI, Vascular Access Nurse
Southcoast Hospitals Group, Charlton Memorial Hospital, Fall River, MA
It does seem odd that a diagram of the upper extremeties could not be added to the EMR, given out advanced computer technology today. I do think marking a drawing is the best method. But if that is not open to you, the next best thing would be a drop down list of all vein names and very specific locations. For instance it is not sufficient to document "cephalic vein" since that vein begins slightly above the thumb and extends the entire length of the arm into the shoulder area. So you could have this list include a specific distance from landmarks such as "at the bend of wrist" (not a recommended site), "1 inch above bend of wrist" or 1in below AC crease". That would create a very long list depending upon how many areas you included. If doing a narrative documentation, this is how I would write it to be very clear about the exact site. This is of special interest to me. When I review medical records in legal cases, it is very often impossible to determine where the site actually was. Nurses are not giving themselves the protection they need by documenting this exact location. They are leaving themselves wide open for liability without this specific documentation. Most of the time it comes down to where the patient said they were stuck. By the time the nurse is deposed on what was actually done years after the venipuncture, the nurse dose not even remember the patient much less where the IV was placed. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thanks for the suggestions. I am also going to insestigate the diagram possibility a little more.
Lynn,
Thank you for that very specific documentation information from a legal standpoint. I was using the standard in our EPIC (computerized) charting system and they all read pretty much the same thing: "Left anterior forearm" or "Right anterior forearm", etc. and naming the vein; however, that really wouldn't be much to go on in a year or two if it came to recalling the exact location on the arm.
I am going to take your suggestion and use the specifics in my narrative note, such as 4 cm below a/c, etc.
Thank you.
Carole
We also use EPIC. I don't have time to chart in the template and also write a narrative for each IV. I will write a note if there was something very important about the IV placement. I click on the generic information such as 22 guage, 1", introcan safety, right anterior forearm and then name the vein in the comments. For instance "R upper mid ulnar vein" or "R lower mid radial vein"; etc. That may not be as specific as a measurement but the class I took a few years ago didn't discuss measuring and there isn't room in our comments for that much information. A diagram with "x marks the spot" is not going to be exactly specific either. If I have placed my IV in the lower cephalic vein I will give a measurement from the wrist to be very specific that I stayed above the danger zone or if getting high in the forearm I will give an approximate measurement as to where the tip is from the AC bend to show that I have not encroached. This last one is important to me as our PE protocols demand a 20 gauge catheter at or above the "AC". I have been able to compromise with them by having the tip in the AC "area" but below the bend so that later movement won't create issues if the IV withstood the power injection. I am also finding that my IVs placed this way are doing better than the IVs placed by other RNs/technicians placed right in the bend even during the power injection inspite of the fact that the rad techs do their best to keep these arms straight.
Question on measuring, do you measure to your insertion site or to where your tip is?
One more question. For pt tolerance. I feel "well, moderate, poor etc" doesn't cut it. I will click on that and then in comments (remember not much space) "ohh" w/stick; no pain/swelling w/brisk (if approp) flush, + return; or other as appropriately brief sometimes tiny return or ++ return if it was so much I could have drawn labs. Pt might say "didn't feel", "OW" etc.
Thanks for the great forum.
Mary Penn RN
Well, I have to tell you that your vein names are not accurate. Superficial veins of the forearm are the cephalic beginning slightly above the thumb and running the entire length of the arm. This is not the radial vein. The opposite side is the basilic vein, not the ulnar vein. Other veins on the palm side of the forearm are median, median cephalic or accessory veins. Use of the wrong names in a legal case could actually be worse than no name at all. RE measurement, I would use the insertion site. For outcomes, you should use words that are broad for legal purposes. Documenting "no pain or swelling" could be argued that you did not look for any other signs or symptoms. You definitely must document blood return. This is critical in my opinion and it must be extremely clear that you are indicating the blood had the color and consistency of whole blood. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Lynn,
Please excuse me if I am in error. I am currently looking at a picture of a right palmer (inner) forearm from the Infusion Nursing Standards of Practice from the Journal of Infusion Nursing Volume 34 Number 1S Janurary/February 2011 page S99. Proceeding from Left to Right (thumb to little finger) are the vein names: Cephalic, Radial, Median Antecubital, Ulnar and Basilic. They give credit to Dorland's Illustrated Medical Dictionary, 30th ed., Plate 53, p. 2015 copyright 2003, used with permission from Elsevier.
This picture looks very similar to the one given to me years ago when I joined the team to refer to when my mind went blank as to vein names.
Is there another source you use? Please feel free to share your sources.
All of us want to chart correctly especially me. I appreciate constructive criticism.
Lynn what would you recommend to chart that your flush after insertion produced no signs that the IV was infiltrated? Pain, infiltration/swelling would be appropriate to an NS flush. I would not expect to see redness or even likely ecchymosis/hematoma formation, if I had that would be charted as a failed attempt.
I would appreciate what you would write as an example of documentation of an appropriately placed IV.
Mary Penn RN Vascular Access Team
PS: I'm sorry I can't resist this. "I have to tell you" Isn't your name on the Standards of Practice Committee? Do you disagree with what is published?
Yes, I was on the INS Standards of Practice Committee that revised the 2006 and 2011 editions, so I do not disagree with what is published in that document.
You are correct that picture does show what is labeled as the ulnar and radial veins and the label states superficial veins. This is from Dorland's Illustrated Medical Dictionary and the committee did not choose these illustrations. I write the A&P chapter of the INS textbook and use Gray's Anatomy and Grant's Atlas of Anatomy. If you have the INS textbook, look at page 164. Ulnar and radial veins are not included as superficial veins. Gray's Anatomy listed the ulnar and radial veins as deep veins. So you would be able to locate them with ultrasound but not by palpation. The picture in the INS Standards does not even make a notation about where the basilic vein transitions from a superficial vein to a deep vein. So this picture does not agree with what is in the INS textbook. thanks for bringing this to my attention.
RE documentation, I would chart, "No signs or symptoms of any complication.". If you list a certain number of signs or symptoms, then a clever lawyer could argue that you did not look for anything other than what you charted. So if you include my statement without specifics of one complication vs another, then you could be more protected in a legal situation. Before and after giving a vesicant medication, I would also document in great detail the characteristics of the blood return you did or did not see. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Lynn,
Thank you for the information on how you would chart. As a Vascular Access Nurse and not an Infusion Nurse I do not administer vesicant drugs. I don't administer any drugs except to declot central lines, or to treat a vesicant infiltrate if I am informed soon enough. I thought this was a discussion of documenting peripheral IV starts. I initially responded to the EPIC problem with charting IV placement in a template. Charting during infusion goes in the patient flowsheet under that particular IV and the IV drug being infused is "supposed" to be linked to that IV in the medication record. I can go nuts trying to figure out what is going on when a pt has had multiple IVs with multiple meds infusing and the meds aren't linked and now they have a phlebitis for me to address.
When I look at an arm I many times see basically what is pictured in the INS standards. Who chose the diagrams? Are we not supposed to be able to trust the source. I do not have the INS textbook. As I mentioned another source, I don't have the name anymore as I have long since lost the picture I used to carry, was basically the same diagram. So my next question is who is going to be the authority on the vein name if sources vary and the most recent INS standards is what it is? Is there going to be an argument in court over the name of the vein when you have described it's location by one legitimate authority and the same location is given another name by someone else? Does anyones arm REALLY look like the textbook or are you sometimes making your best choice as to what vein that is? There have been times I could swear the patient had two median antebrachial veins by the position/length of the vein and number of veins I see going across the forearm. You didn't make any reference to the median antebrachial vein in your comment. By either name you may have described the same location of a visible vein. The Ulnar and Radial Arteries are deep, I don't ever recall being taught that the vein was nearby and deep as the Brachial veins are with the Brachial artery. I will do some more research.
I am currently working to get my VA-BC but I certainly can see the benefit of getting my CRNI so that I can be the best resource I can to our nurses who infuse. I do belong to both organizations. I am working as hard as I can to improve vascular access care at my facility.
Mary Penn
It does sound like you are working hard on these issues. I have always taken the position that you can not separate vascular access from infusion therapy. I am giving a presentation around the country now about this issue. To place a PIV, you must know what infusion therapy is planned. To deal with a complication, you must know what infusion therapy went through that site. To decide if a CVAD or midline is indicated, you must know what infusion therapy is ordered. To administer any IV medication, you must know exactly where that catheter is located and confirm its patency. You simply can not separate those into 2 separate practices. In my presentation, I use the old Sinatra song of Love and Marriage, you can't have one without the other. The same is true for infusion therapy and vascular access. I would strongly recommend that you set a career goal to become CRNI.
You described very well the problems I face when trying to decipher a medical record to determine what vein or catheter or lumen was used for what infusion. And therefore can I decide that the nurses practice did or did not meet the standard of care. There is a discrepancy between the illustrations as we found earlier. If you documented a deep vein instead of a superficial vein that was actually used, this is probably not going to cause a huge issue in a legal case. That would depend on the facts specific to each case. Lets hope you never have to find out about this through an actual case. I just wish I found legal cases with that much detail! Most of the time all I find is "right arm" or "left hand". I have also already sent a message to another committee member about this issue. Both references would be acceptable to support your practice. But you do need to understand that there are superficial veins that we can palpate and see. Deep veins are under the muscle tissue and we must have ultrasound to find them. Perforating veins connect between the superficial and deep veins. That is basic venous anatomy. I would also strongly agree that no human is exactly the same as a textbook picture. Brachial veins are definitely deep veins and are located in the same protective sheath as the brachial artery. The illustration in the INS Standards contains the brachial veins and would lead one to believe that they are superficial veins. INS is not the authority assigning vein names. As mentioned there are 3 anatomy resources we have identified and there is conflicting information. All of those resources would be included in any legal discussion. Another thing to understand about a legal case - if it goes to a jury trial, and most cases do not go that route, the jury decides which facts to accept. So they could reject what one expert says in favor of another expert for any one of a number of reasons. So basically the jury decides which expert to believe. In 3 trials I have testified for hours, only to have the jury decide for the oppposite side in 2 cases and the other case is still pending. Many differences in the appearance of human veins is the very reason that I recommend using the measurement or distance from landmarks as I think this gives a better explanation of what was used. As I mentioned the cephalic vein runs the entire length of the arm, so using that vein name alone would not be sufficient - just one example. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thank you for the references. I have looked at Gray's anatomy on line. It is pasted below. I can't afford the book. I plan to purchase the other you referenced. Please note in the reference from Gray's I was able to retrieve online that the basilic vein is not mentioned at all as a deep vein. I won't be able to look at your other source until it comes as those pages were not able to be reviewed when I looked at it. My coworker and I went around looking at some arms. My coworker was taught approx 25 years ago to name them as you named them when she practiced on the east coast. When she practiced on the west coast they named them as ulnar and radial. We were able to identify ulnar and radial veins that were superficial enough to see along with the cephalic, median antebrachial and basilic vein. I would appreciate hearing what the committee has to say on the differing sources. Thank you.
Mary Penn
The Veins of the Upper Extremity and Thorax
I have read your recommendation of using the measurement or distance from landmarks however, I am not sure how to do this in a RMR what just asks for a checkoff in the box cephalic or Basilic. Would you want the nurse to free text a note each time she/he chose the vein name? But do not see another way due to the fact that teh cephalic and basilic are long not just in one part of the arm.
Any thoughts on how not to mandate a written note as well as checking the box?
thank you very much for all of your expertise
dee morrisond
In reviewing EMRs, I can definitely say we are a long way from having a good system. I always come up with a huge list of questions that are not addressed by what I see on the paper. I can't tell you how to put information into your specific system. I can tell you what the standard of care is for documentation. The SOC is established through documents such as the INS Standards, other guidelines, your nurse practice act and rules and regulations, and published studies. All of these should be used as references to create internal policies and procedures. Should you alter the documentation to fit the system? I think we should alter the system to meet the standard of care. As an expert, I would say that the SOC is to document the specific vein name and the exact location of the puncture site by anatomical descriptors. So each person will need to figure out a way to work with their current system in a manner that meets the SOC. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Lynn, I realize that this is from long ago, but you said you were going to discuss with the INS committee the issue of varing sources of names of veins. I am still awaiting a reply. You also mention that that the radial and ulnar are found in the muscle tissue and are deep. I would like to mention that many of the very frail elderly patients I start IVs in have lost a great deal of muscle tissue. Is it not possible that the veins might now be visible in patients with little muscle tissue and no fat in the forearm? Some times they are so frail that we can see the basilic vein in the upper arm when we start PICCs and chart it as approximately 0.5 cm deep, rarely 0.25 - 0.5 cm deep. I have seen a vein visible into the armpit on very frail patients. How do your textbooks describe that? Once the basilic vein of the upper armi was so shallow I finally decided to use the IV needle from the kit and not the set up to attach to the ultrasound after I did my full ultrasound exam. Just the weight of the ultrasound compressed the vein even though I had a tourniqet on. Patient anatomy is affected by other conditions, such as muscle wasting, something not very uncommon in frail elderly. Maybe you need to think about that before you correct someones choice of terminology. Again, we are here as adult learners and professionals, you need to speak accordingly.
Mary Penn RN
St Charles MO
I am not sure what I have done to generate such sharp, unprofessional messages from you. The Infusion Nursing Standards of Practice Committee is now being formed to revise the next document. This committee will begin work in the fall 2013 and the new document will be released in early 2016. I have sent your comments to the chair of this committee who will assign this section to someone on this committee. You will not receive new information until the 2016 document is released. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Lynn thank you for letting me know what the final outcome of my question as to name veins. I asked you a legitimate question. It has been months. I do believe this all started with your initial subject reply to my simple response to another RN who was trying to make the best use of the EPIC system she could. Look back through the thread. "I have to tell you" in a subject line and repeated again is unprofessional, especially coming from someone who lists her credentials as an educator.
After calling me out on how I could make my self subject for a law suit for naming a vein wrong, you then said you wished you saw more charts documented as thoroughly as mine. I know I have more to learn and that is why I am here. But I have observed your cutting remarks to many others who I don't see on the site anymore. Such a shame. I have always graduated at the top of my class, part of that because I was always willing to help the person who had the most difficulty. You can't help them when you make them feel stupid if they ask a question wrong or don't answer a question exactly right. You complement them on what they have right and go on from there. If you don't understand something they say you ask for clarification especially if you think they have left something out.
When you point fingers at others, make sure you know how many fingers are pointing at yourself. Please remember, we are here to LEARN. I have thanked you for many things you have shared, I have learned from you and many others. But I have also noted that you don't have all of the answers. I am just trying to get you to be more respectful so that others unlike me won't get scared away from this site.
Respectfully,
Mary Penn RN
St Charles, MO