Document observations. Record the date and time of the activity. Describe the patient status. Include an assessment of the IV site, location and appearance. According to Male Nurse Magazine, charting should be accurate and should be a statement of facts only.
Record interventions. Describe how the IV was converted to a saline lock. Include items or equipment used. Items used may include antiseptic solution, flush solution and syringes. Document whether the dressing was changed or reinforced during the procedure. Interventions should be charted as soon after they occur as possible.
Document patient response. Describe how the patient tolerated the procedure. The documentation should give a full account of the activities.
Describe any unusual events and what was done about them. Document when the physician was notified and any additional instructions. Failure to document what you did as a result of an unusual event can be viewed as neglect.
Document any patient teaching. This is a component of good care and shows there was communication between the patient and the nurse.
Complete the charting with your signature and title. Be sure not to leave blank spaces before or after your signature.