VGH LINE INSERTION PROCEDURE NOTE                                                     FAQ/HELP

8-digit MRN:

LINE 1:        
Procedure: New line Rewired line    
Side: Right Left    
Site: Internal jugular Subclavian Femoral Antecubital
  Radial artery      
Line type: Single lumen Double lumen Triple lumen Dialysis
  Arterial PA Catheter Introducer (Cordis) PICC
Department: ICU E.R. O.R. Ward
Insertor is a: Staff physician Resident MSI Nurse
  Other (specify)    
Specialty: Anesthesia Medicine Surgery ICU
  ER Other (specify)  
Procedure was: Urgent Elective During code resuscitation
Sterile precautions: Jewelry removed (rings, watches, bracelets)    
  Hands washed      
  Mask      
  Sterile gloves      
  Sterile gown      
  Surgical cap      
  Site disinfected with chlorhexidine/EtOH sol'n    
  Prep sol'n allowed to dry      
Draping: None Local Half sheet Full body
Ultrasound probe used: No Prior to insertion Actively during insertion
Sutured in place: Yes No    
Sterile dressing: Yes No    
Number of pokes: Number of passes with each poke:
Complications: None Yes (specify):
Comments:
   
LINE 2:  
   
Procedure: New line Rewired line    
Side: Right Left    
Site: Internal jugular Subclavian Femoral Antecubital
  Radial artery      
Line type: Single lumen Double lumen Triple lumen Dialysis
  Arterial PA Catheter Introducer (Cordis) PICC
Department: ICU E.R. O.R. Ward
Insertor is a: Staff physician Resident MSI Nurse
  Other (specify)    
Specialty: Anesthesia Medicine Surgery ICU
  ER Other (specify)  
Procedure was: Urgent Elective During code resuscitation
Sterile precautions: Jewelry removed (rings, watches, bracelets)    
  Hands washed      
  Mask      
  Sterile gloves      
  Sterile gown      
  Surgical cap      
  Site disinfected with chlorhexidine/EtOH sol'n    
  Prep sol'n allowed to dry      
Draping: None Local Half sheet Full body
Ultrasound probe used: No Prior to insertion Actively during insertion
Sutured in place: Yes No    
Sterile dressing: Yes No    
Number of pokes: Number of passes with each poke:
Complications: None Yes (specify):
Comments: