Documentation Flashcards
7 cards from real VABC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation flashcards as text
When a vascular access device is removed, which information must be included in the documentation?
Answer: Catheter integrity, reason for removal, and site condition post-removal
Removal documentation must capture that the catheter was removed intact, the clinical reason for removal, and the appearance of the site afterward.
A nurse inserts a peripheral IV in a pediatric patient. Which additional documentation element is especially important compared to adults?
Answer: Patient weight and age-appropriate catheter size selection rationale
Pediatric documentation should include weight and justification for catheter gauge selection to demonstrate age- and size-appropriate practice.
In electronic health records, which practice is considered a documentation error for vascular access?
Answer: Copying and pasting prior assessment data without re-evaluating the patient
Copy-pasting outdated assessment data without reassessing the patient creates inaccurate records and constitutes a documentation error.
Which statement about late entries in vascular access documentation is correct?
Answer: Late entries should be labeled as such with the time and date written, and the reason for the delay noted
A late entry must be clearly labeled as such, include the actual time written, and state why it was not documented in real time to maintain record integrity.
What should a clinician document if a patient refuses a recommended central venous catheter?
Answer: Patient's refusal, education provided, and alternative plan offered
Documenting patient refusal protects the clinician legally and confirms that education and an alternative care plan were offered.
When documenting IV fluid administration, which element is critical for accurate intake and output calculation?
Answer: Volume infused and time period of infusion
Recording the volume infused and the time frame allows accurate calculation of fluid intake, which is essential for monitoring fluid balance.
Under The Joint Commission standards, how frequently must central venous catheter sites be assessed and documented in the acute care setting?
Answer: At least every 8–12 hours per shift or per facility policy
TJC and INS standards require central line site assessment and documentation at minimum per shift (every 8–12 hours) or as dictated by facility policy.