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Standard PICC placement order form
I'm putting together a standard MD order form for PICC line placement. I was wondering if anyone had one they liked out there. We are changing our protocol to 0.9NS flush and using heparin capping only if MD wants it.
Here's a copy of our

Here's a copy of our in/outpt PICC order form.  I've also attached a copy of an adult inpatient central line maintenance order form (also have inpt pedi, and in/outpt adult to cover issues with vendors, etc).

We recently revised the PICC order form, and has one more committee hurdle to cross (about catheter exchange), but the rest is good to go.  If we decide to use any other catheters on a regular basis and need them to be represented on the order sheet - we'll add them (e.g. we use HDC v-caths on peds/neonates more often now).

These forms get us the tools we need, with little room for MDs forgetting/not knowing what to order.

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems 

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

Here is our order sheet. 
Here is our order sheet.  Hope this helps.  Susan
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