Our facility is currently in the process of evaluating our initial PICC Insertion documentation process. We currently document in two different places. We have our paper form that we use. It has everything from total length of the catheter, how many cm out, what our technique was. It has a picture with which we place insertion site and tip visualization on x-ray. We also document in the EMR (PowerChart) the insert. This too captures total length and cm out and x-ray confirmation, but no picture. Because we use SurgiNet for documentation of procedures as it creates charges they are looking at us possibly documenting there as well. But essentially we would not be able to document anything line specific. It would capture our start and stop time, Time Out, supplies we used.
I want to find out what other places do for documentation and charge capturing.
We document in he EMR, we use Epic, and then on a QA spreadsheet. On the spreadsheet it's limited information. Still contains length, # of attempts, arm used etc. We also use it to note the level of difficulty. We use this info for productivity and to do a search on new orders to look for history of prior line placement. If found we can look at notes to see if there were problems etc. We will also note here if this is a patient that we send directly to IR for line and why. Saves time and trouble.
Debra Rivie
Long Beach Memorial Medical Center
Long Beach, CA
Debra Rivie RN VA-BC
Long Beach Memorial Medical Center
Long Beach, CA