Sample Documentation

Sample Documentation of Expected Findings

IV catheter on right hand discontinued with catheter tip intact. Site free from redness, warmth, tenderness, or swelling. Gauze applied with pressure for one minute with no bleeding noted. Dressing applied to site.

Sample Documentation of Unexpected Findings

IV catheter on right hand discontinued with IV catheter tip intact. Site free from redness, warmth, tenderness, or swelling. Gauze applied with pressure for one minute. Bleeding noted to continue around gauze dressing. Pressure held for five minutes, and hemostasis achieved. Dressing applied to site.