Nurse inserting IV

How to Document an IV Site Assessment: A Guide for Nurses

Accurate documentation of an IV site assessment is an essential nursing responsibility that supports patient safety, enhances continuity of care, and ensures legal protection. Whether you're working in acute care, long-term care, or home health, your assessment of a vascular access site must be thorough, timely, and clearly recorded.

This blog outlines the key components of IV site assessment documentation and provides best practice tips to support nurses in maintaining high standards of care.

Why IV Site Documentation Matters

Proper IV site documentation:

  • Helps detect complications early (e.g., infiltration, phlebitis, infection)
  • Supports appropriate clinical decision-making (e.g., site rotation, device removal)
  • Meets legal and regulatory requirements
  • Ensures compliance with institutional policies and professional standards

What to Include in Your IV Site Assessment Documentation

When assessing and documenting a peripheral IV site, include the following components:

1. Date and Time of Assessment

Always document the exact date and time of the assessment. This helps with trending changes over time and aligns with institutional charting protocols.

2. Site Location

Clearly indicate the anatomical location of the IV catheter (e.g., "right dorsal hand," "left forearm").

3. Catheter Type and Gauge

Note the type and size of the catheter in use:

  • Example: “20G short peripheral catheter”

4. Site Appearance

Describe the condition of the insertion site and surrounding tissue:

  • Normal: “Site clean, dry, intact. No redness, swelling, or drainage.”
  • Abnormal: “2 cm area of redness around site. Slight edema present. No drainage.”

Use objective, measurable language (e.g., size of redness, length of swelling) and avoid vague terms like "looks okay."

5. Patency and Function

Assess whether the line flushes and infuses easily:

  • “IV flushed with 5 mL NS; no resistance noted. Positive blood return.”
  • If not patent: “Resistance noted on flush, unable to aspirate blood return.”

6. Securement and Dressing Integrity

Document whether the IV is properly secured and if the dressing is intact:

  • “Transparent dressing dry and intact. Securement device in place.”

If the dressing is soiled, peeling, or loose, that should be noted along with your intervention.

7. Patient Reports/Symptoms

Include any symptoms the patient reports:

  • “Patient reports no discomfort at site.”
  • Or: “Patient reports burning sensation during flush.”

This is particularly important when complications like infiltration or phlebitis are suspected.

8. Interventions Performed

If any actions were taken, document them thoroughly:

  • “Dressing changed per protocol due to loosening.”
  • “IV discontinued due to suspected phlebitis; new site initiated in left forearm.”

9. Signature or Initials

Complete the entry with your full name, title, or approved initials depending on your facility’s policy.

Example Documentation Entry

“07/02/25, 10:00 AM – 20G SPC in right forearm. Site clean, dry, and intact. No redness, swelling, or drainage. IV flushed with 5 mL NS without resistance. Blood return present. Transparent dressing intact. No patient complaints. – C. Garrison, RN”

Tips for Accurate Documentation

  • Be objective and factual – Avoid assumptions or subjective language.
  • Use standard terminology – Follow facility-approved assessment tools (e.g., INS Phlebitis Scale or Infiltration Scale).
  • Chart in real-time – Delays in documentation can lead to errors or omissions.
  • Follow policy – Ensure your documentation aligns with your institution’s IV therapy guidelines.

Enhance Your IV Skills with Online Education

If you’re looking to improve your IV therapy skills, including documentation practices, consider enrolling in our comprehensive online course: Basics of Peripheral IV Therapy: Current Standards of Practice

This course covers essential topics such as site selection, catheter types, insertion techniques, complication management, and thorough documentation strategies—all aligned with the Infusion Nurses Society (INS) standards.

Conclusion

Proper documentation of IV site assessments is more than a checkbox—it’s a cornerstone of safe, effective nursing care. By staying consistent and detailed in your charting, you not only improve patient outcomes but also protect yourself and your license. Stay informed and confident by investing in ongoing IV education and best practices.