Vascular Access Surveillance Log
Document and monitor vascular access assessments, findings, and interventions.
Patient Full Name
*
First Name
Last Name
Patient ID (Last 4 digits)
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Assessment
*
Hour Minutes
AM
PM
AM/PM Option
Type of Vascular Access
*
Arteriovenous Fistula (AVF)
Arteriovenous Graft (AVG)
Central Venous Catheter (CVC)
Other
Access Site Location
*
Left Arm
Right Arm
Neck
Chest
Other
Assessment Findings
*
Normal bruit/thrill
Absent bruit/thrill
Swelling
Redness
Pain
Bleeding
Clotting
Other
Interventions Performed
*
None
Flushed access
Dressing change
Consulted physician
Other
Complications Noted
*
None
Infection
Thrombosis
Bleeding
Other
Additional Comments or Notes
Staff Name and Role
*
Signature of Staff
*
Submit Log Entry
Submit Log Entry
Should be Empty: