Title Page

  • Patient Name

  • Room Number

  • MRN

  • Conducted on

  • Prepared by

  • Location
  • Personnel


  • Type of Line

  • Is order in EMR

  • Indications for use

  • CHG Bathing done

  • Does patient have documented allergy to CHG?

  • Documented Tubing changes every 96 hours

Visualization of Line

  • SwabCaps in place on all appropriate hubs

  • Biopatch appropriately placed at insertion site

  • Dressing clean/dry/intact

  • Is Line sutured appropriately?

  • Is all tubing labeled

  • Do all lumens have blood return, flush appropriately, or have an infusion currently active

  • Is dressing labeled with initials / date

  • If secured with securement device, is it used appropriately

Observation of Nurse

  • Did Nurse wash hands prior to accessing line

  • Is nurse proactive in getting line taken out when appropriate.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.