What do you document for an IV assessment?

September 28, 2025 •

4 min read

Over 90% of hospitalized patients receive intravenous (IV) therapy, making accurate documentation of an IV assessment a fundamental nursing skill. Proper charting is vital for tracking a patient's condition, ensuring continuity of care, and mitigating risks. This guide will walk you through the essential components of thorough IV documentation.

Quick Summary

Proper IV assessment documentation includes recording the date and time, site location, catheter details, site appearance, patency, dressing integrity, and patient symptoms to ensure continuity of care and monitor for complications like infiltration or phlebitis. Timely and objective charting protects both the patient and the healthcare provider.

Key Points

Chart Timely and Accurately: Documenting IV assessments in real-time prevents errors and omissions, ensuring accurate, up-to-date patient records.
Detail Site Location and Appearance: Specify the anatomical vein used and provide an objective description of the site's condition, noting any redness, swelling, or drainage.
Verify Catheter Patency: Document that the IV flushes easily and has a positive blood return to confirm the catheter's proper function and position.
Record Dressing Integrity: Note that the IV dressing is clean, dry, and intact, and record any interventions if it is loose or soiled.
Monitor for Complications: Be vigilant for and document specific signs of infiltration (coolness, swelling) and phlebitis (redness, warmth, pain) to facilitate early intervention.
Include All Insertion Details: For new IVs, document the date, time, catheter gauge, number of attempts, and patient tolerance to establish a thorough baseline.
Document Patient Symptoms: Always record the patient's subjective reports of pain, discomfort, or burning sensations, which are vital clues for potential issues.

Why Comprehensive IV Documentation is Critical

Accurate and meticulous documentation is not just a procedural step; it's a cornerstone of safe and effective patient care. For intravenous therapy, which can carry a risk of complications like infection, infiltration, and phlebitis, detailed charting provides a chronological record of the site's condition and any interventions. This helps other healthcare professionals track changes over time, facilitates timely interventions, and serves as legal protection for the clinician. Missing or incomplete records can lead to delays in care and potentially serious patient harm.

Core Elements of IV Assessment Documentation

When assessing and documenting a peripheral intravenous (IV) site, a standardized approach ensures no critical information is missed. The following elements are universally recognized as essential for complete documentation:

Documenting the Initial IV Insertion

Upon a new IV start, specific details are recorded to establish a baseline:

Date and Time of Insertion: The exact time is critical for determining how long the catheter has been in place, which relates to best practice for site rotation.
Device Details: Document the type, gauge, and length of the catheter inserted. For example, "20-gauge, 1-inch peripheral catheter."
Site and Vein Location: Use precise anatomical terminology (e.g., "right cephalic vein, left dorsal hand") to clearly identify the site.
Attempts: Record the number of attempts and location of any unsuccessful insertions. This provides context for the patient's venous access and potential bruising.
Dressing Type: Note the type of dressing used, such as a transparent semipermeable membrane (TSM) dressing.
Patient Response: Include the patient's verbal or non-verbal response to the procedure, using objective language.

Documenting Ongoing IV Assessments

For each subsequent assessment, the focus shifts to monitoring the site's integrity and function. Regular, timely documentation is crucial for early detection of complications.

Checklist for a routine IV assessment:

Date and Time: Chart every assessment with the precise date and time.
Site Appearance: Describe the surrounding skin and insertion point. Look for signs of:
- Redness (Erythema): A red area around the site may indicate phlebitis or infection.
- Swelling (Edema): Swelling or puffiness can be a sign of infiltration or extravasation.
- Tenderness/Pain: The patient's reported discomfort is a key indicator of issues.
- Drainage: Document any discharge, noting its color, odor, and amount.
Dressing Integrity: Confirm the dressing is clean, dry, and intact. Any peeling, soiling, or dampness should be documented along with an intervention.
Patency: Assess if the line flushes easily without resistance. Note if there is a positive blood return. A sluggish or resistant flush is a red flag.
Infusion Rate and Status: Record the type and rate of infusion, and if the line is currently in use or locked.
Patient Report: Always document any subjective reports from the patient, such as a burning sensation or discomfort.

Documenting Complications

When complications arise, thorough and immediate documentation is paramount. Clear, objective details can influence treatment and outcomes. Utilize standard scales, such as the Infusion Nurses Society (INS) Phlebitis and Infiltration Scales, for consistent, measurable findings.

Comparison of Infiltration vs. Phlebitis Documentation


Documentation Component	IV Infiltration	IV Phlebitis
Mechanism	Leakage of non-vesicant fluid into surrounding tissue.	Inflammation of the vein's inner lining.
Site Appearance	Swelling, skin blanching, coolness to touch, taut skin, leakage.	Redness, warmth, tenderness, swelling, palpable venous cord.
Flow Rate	Decreased or stopped IV flow, possible pump alarms.	Infusion may slow or stop due to vein damage.
Patient Symptoms	Discomfort, pain, tightness at the site.	Localized pain and tenderness along the vein.
Interventions	Stop infusion, elevate limb, remove catheter, apply warm or cold compress per policy.	Stop infusion, remove catheter, apply warm compress.
Legal/Clinical Impact	Potential for tissue damage; documentation supports standard of care.	Risk of infection or thrombosis; detailed records confirm appropriate intervention.

Documenting IV Catheter Removal

When an IV is discontinued, documentation is required to finalize the record. This includes:

Date and Time of Removal: Record when the catheter was pulled.
Reason for Removal: State why the IV was discontinued (e.g., completion of therapy, infiltration, patient discharge).
Site Assessment: Describe the post-removal site appearance (e.g., "site intact, no redness or drainage").
Patient Response: Note how the patient tolerated the procedure.
Confirmation of Catheter Tip Intactness: For longer lines like PICCs, confirming the tip's integrity is important.

Final Thoughts on IV Documentation

Effective IV documentation is more than just charting; it's a patient safety tool. By following standardized procedures and being consistently detailed, healthcare providers can enhance communication, ensure continuity of care, and protect both themselves and their patients. Regular review of facility protocols and staying up-to-date with current standards, such as those from the Infusion Nurses Society, is the best practice for professional excellence. For more information on infusion therapy, visit the Infusion Nurses Society's website at https://www.ins1.org/. Consistent, accurate, and objective documentation reflects a high standard of care and directly contributes to improved patient outcomes.

Frequently Asked Questions

Immediately after inserting an IV, you should document the date and time of insertion, the location of the vein accessed, the gauge and length of the catheter used, the number of insertion attempts, and the type of dressing applied.

The frequency of IV site assessments and documentation varies by institution policy and patient acuity. However, regular monitoring is standard practice, often occurring every few hours, and always before and after administering medication or fluid.

When documenting infiltration, you would note signs like swelling, coolness, and blanching at the site. For phlebitis, you would document redness, warmth, tenderness, and a palpable cord along the vein.

Documenting the patient's response, especially if they reported significant pain or discomfort, provides a complete picture of the procedure. It can be crucial information for future clinicians attempting IV access or for legal protection.

When an IV is removed, you must document the date and time of removal, the reason for removal (e.g., no longer needed, complications), and the condition of the site after the catheter was pulled. Note if the site is intact with no signs of redness or drainage.

Yes, it is essential to document negative findings, such as "site clean, dry, and intact, no redness or swelling." This proves that the site was assessed and found to be in good condition, which is a crucial part of the patient's medical record.

Using a standardized scale provides a consistent, objective measure for assessing complications like phlebitis or infiltration. This ensures clarity in communication between healthcare providers and leads to more precise, actionable documentation.