US PIV: Documentation

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Full documentation guidelines are typically facility specific. But at a minimum include:

  • Vein anatomic name, laterality
  • Catheter length (typically 45-48 mm for long catheters used in US placement)
  • Catheter gauge (18, 20, 22 ga versions available of 45-48 mm length)
  • Number of attempts
  • Date and time of insertion
  • Patient response (“pt tolerated procedure well”)

Billing for the placement with US requires capturing an ultrasound image, at least of the vessel prior to cannulation and/or with the catheter in place.

Example
A 48 mm 20 ga catheter was introduced under ultrasound guidance in the R cephalic vein @ 12:00 on 1/1/2020. Only 1 attempt was required. It aspirated easily and the IV was clamped and capped. Skin prep followed by a clear dressing was applied to secure the IV.

Billing

Back to US PIV flowchart