IV Access Assessment Form
Complete this form to assess intravenous (IV) access suitability and condition for patient care.
Patient Full Name
*
First Name
Last Name
Date and Time of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Patient Identification Number (if applicable)
Reason for IV Access
*
Please Select
Medication Administration
Fluid Replacement
Blood Product Administration
Nutritional Support
Other
IV Site Assessment
*
Rows
Normal
Redness
Swelling
Tenderness
Leakage
Insertion Site
1
2
3
4
5
Surrounding Skin
6
7
8
9
10
Vein Condition at IV Site
*
Good (easily palpable, visible)
Moderate (palpable but not visible)
Poor (difficult to palpate/see)
Other
Type of IV Device Used
*
Please Select
Peripheral IV Catheter
Central Venous Catheter
Midline Catheter
Peripherally Inserted Central Catheter (PICC)
Other
Assessment of Potential Complications (select all that apply)
*
None
Phlebitis
Infiltration
Infection
Occlusion
Other
Risk Factors Present (select all that apply)
Diabetes
Immunocompromised
History of Difficult Access
Current Infection
Other
Overall IV Access Assessment
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Additional Notes or Recommendations
Assessor's Signature
*
Submit Assessment
Submit Assessment
Should be Empty: