CVC Checklist → Clinical Note Generator
Procedure Date:
Time:
Operator:
Assistant:
Supervisor:
BEFORE THE PROCEDURE
Patient identity checked?
Yes
Appropriate consent completed?
Yes
All equipment available?
Yes
Correct type/size of line available?
Yes
Is there a coagulopathy?
Yes
No
Known drug allergies?
Yes
No
Infection control precautions in place?
Yes
No
Is help required?
Yes
No
TIME OUT
Team members identified / roles allocated?
Yes
Is patient position optimal?
Yes
Operator confirms guidewire will be removed:
Yes
Ultrasound available and set up?
Yes
SIGN OUT
Able to aspirate blood from all lumens?
Yes
Correct caps / connectors used?
Yes
Correct dressing applied?
Yes
Guidewire confirmed as removed?
Yes
Chest X-ray required?
Yes
N/A
If CXR required, line position satisfactory?
Yes
CXR Pending
N/A
Pneumothorax excluded?
Yes
N/A
Correct placement should be checked using at least two of the following methods
CVP waveform present / venous pressure recorded?
Yes
No
N/A
cmH
2
O
Ultrasound confirms placement?
Yes
Paired venous/arterial gases taken?
Yes
No
mmHg (venous)
mmHg (arterial)
LINE INSERTION DETAILS
Location line inserted:
Critical care
Theatres
Radiology
Ward
ED
Other:
Indication for insertion:
Vaso-active drugs
Difficult IV access
TPN
Other:
Central line type:
CVC
Vascath
Number of lumens:
1
2
3
4
5
Side:
Left
Right
Anatomical site:
Internal jugular
Subclavian
Femoral
Ultrasound imaging used (multiple permitted):
Prior to procedure
During procedure
Not used
Length of line (cm):
Length secured at skin (cm):
Number of attempts:
Complications:
Yes
No
ANTT:
Hand hygiene
Theatre hat
Face mask
Sterile gown + gloves
Sterile field
2% chlorhexidine/70% alcohol
If answered NO to any of the above, please give reason:
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