PIVAudits

PIV Audits

* Indicates required field

Auditor Name *

AUDIT ID Number *

Please choose the audit ID that corresponds to your unit name and the # of the audit you are completing.

Date of Audit (MM/DD/YYYY) *

ROOM # *

Date Inserted (MM/DD/YYYY) *

Unit/Area of Origin *

# of Days in Place (Day 1 is date IV was inserted) *

If >4 days, documentation exists for need of extension? *

Yes No

Nurse has documented patency of line on flush within the last 8 hrs *

Yes No

Issues documentation in site assessments *

PIV Gauge *

If other, please specify *

PIV Location on the Body *

Redness? *

Yes No

Swelling? *

Yes No

Drainage? *

Yes No

Hematoma? *

Yes No

Bruising? *

Yes No

Leaking? *

Yes No

Pain on Palpitation? *

Yes No

S/S of Phlebitis? *

Yes No

Blood in Tubing/Debris under dressing? *

Yes No

Is date of insertion written on dressing? *

Yes No

Is ALL IV tubing dated and timed? *

Yes No Not Applicable

Comments *

Submit