Central Venous Catheter (CVC, Central Line) Placement
Date: <____>
Time: <____>
Indication: Hemodynamic monitoring/Intravenous access
Resident: <____>
Attending: <____>
A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in a dependent position appropriate for central line placement based on the vein to be cannulated. The patient’s <right/left> < neck/shoulder/groin> was prepped and draped in sterile fashion. 1% Lidocaine was used to anesthetize the surrounding skin area. A triple lumen <9-French> Cordis catheter was introduced into the the <subclavian/internal jugular/common femoral vein> using the Seldinger technique <and under ultrasound guidance>. The catheter was threaded smoothly over the guide wire and appropriate blood return was obtained. Each lumen of the catheter was evacuated of air and flushed with sterile saline. The catheter was then sutured in place to the skin and a sterile dressing applied. Perfusion to the extremity distal to the point of catheter insertion was checked and found to be adequate. <Attending/Resident> was present for the entire procedure.
Estimated Blood Loss: <____>
The patient tolerated the procedure well and there were no complications.
Other procedure note examples:
- Endotracheal Intubation
- Central Line (CVC) Access
- Arterial Line
- Lumbar Puncture
- Thoracentesis
- Thoracostomy (Chest Tube)
- Swan-Ganz Catheter Placement
Also, thank you to my two favorite websites for helping me write notes in the hospital:
My name is Andrew and I am a first year resident training to be an ophthalmologist. I created ShortWhiteCoats to provide medical students, residents, and the public with all the information I spent so many hours looking for during medical school.
2 comments
mary 4278
January 13, 2016 at 6:37 am (UTC -4) Link to this comment
I would make the following changes to this:
The patient was placed in (name the position). (You can delete for central line insertion since you can title the note as such). The patient’s <right/left> < neck/shoulder/groin> was prepped with a2% Chlorhexidine & 70% alcohol skin antiseptic and draped in a sterile fashion and maximal barrier precautions were used. 1% Lidocaine (.05 mls) was used to anesthetize the insertion site. The <subclavian/internal jugular/common femoral vein> was accessed using ultrasound guidance and a triple lumen <9-French> Cordis catheter was introduced using the Seldinger technique. The catheter threaded smoothly over the guidewire and advanced easily into the vein and a brisk blood return was obtained from each lumen. Each lumen was then easily flushed with 10 mls of sterile normal saline. The catheter was sutured in place at the suture wing (size ie 3.0 nylon). There were no signs and symptoms of any CVAD related insertion complications and the patient tolerated the procedure well. (you can also list any complications that the pt may have had). A chest xray has been ordered to confirm tip placement or a chest x ray was completed and it shows that the tip is at the cavoatrial junction. )
Andrew
March 27, 2016 at 10:59 am (UTC -4) Link to this comment
Thank you!