Central Line → Clinical Note Generator

Procedure details

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

Coagulation/platelets and anti-coagulants checked?

Yes

Drug allergies checked?

Yes

Infection control precautions in place?

Yes No

Is help required?

No Yes

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 cmH₂O

Ultrasound confirms placement?

Yes

Paired venous/arterial gases taken?

Yes No kPa (venous) kPa (arterial)

LINE INSERTION DETAILS

Location line inserted:

Indication for insertion:

Vaso-active drugs Difficult IV access TPN Other:

Central line type:

CVC Vascath

Number of lumens:

LOT number:

Side:

Left Right

Anatomical site:

Ultrasound imaging used (multiple permitted):

Prior to procedure During procedure Not used

Length of line (cm):

Length secured at skin (cm): (enter 0 if inserted to the hub)

Number of attempts:

ANTT:

If answered NO to any of the above, please give reason:

Complications:

No Yes