23.11 Sample Documentation

Sample Documentation of Expected Findings

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

Sample Documentation of Unexpected Findings

IV catheter on the right hand was discontinued. IV catheter tip was intact. Site free from redness, warmth, tenderness, or swelling. Gauze applied with pressure for one minute but bleeding was noted to continue around the gauze dressing. Ongoing pressure was held for five minutes until hemostasis was achieved.