Sample Documentation

Sample Documentation of Expected Findings

Initiated IV infusion of normal saline at 125 mL/hr using existing 22-gauge IV catheter located in the right hand. The IV site is free from pain, coolness, redness, or swelling. 

Sample Documentation of Unexpected Findings

Attempted to initiate IV infusion in right hand with existing 22-gauge IV catheter. IV site free from pain, redness, or signs of infiltration. IV site flushed readily with normal saline. Normal saline IV fluids connected at 200 mL/hour with immediate leaking around infusion site. Swelling noted superior to infusion site. Fluids stopped immediately.