Central Venous Catheter Access Assessment Form

Central Venous Catheter Access Assessment Form
Use this form to assess the condition, patency, and safety of a central venous catheter access site and record any required actions or follow-up.
Patient and Catheter Information
Patient Name
First NameMiddle NameLast Name
Medical Record Reference
Date of Assessment
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Assessor Name
First NameMiddle NameLast Name
Assessor Role
Catheter Type
Access Site / Location
Insertion Date (if known)
Indication for Catheter Use
Access Site Assessment
Redness/Erythema
Swelling
Warmth
Tenderness/Pain on Palpation
Drainage/Discharge
Dressing Integrity
Catheter Securement
Leakage or Wetness
Overall Site Appearance

1
2
3
4
5
1 is Poor, 5 is Excellent
Site Clean, Dry, and Intact
Catheter Function and Patency
Blood Return
Flush Resistance
Ability to Infuse or Aspirate
Lumen Status
Occlusion Alarms or Resistance History
Other
Recent Access Problems
Multi-Lumen or Port Assessment
Rows Blood Return Flush Ease Notes
Lumen/Port 1
Lumen/Port 2
Lumen/Port 3
Complications and Symptoms
Observed or Reported Complications and Symptoms
Other
Fever or Chills Present?
Suspected Infection?
Bleeding Present?
Edema Present?
Pain Level
Burning Sensation Severity
Catheter Position Concern
Additional Clinical Notes
Interventions, Plan, and Acknowledgment
Immediate actions performed
Recommended next steps
Follow-up timeframe
Plan details
Provider notification and instructions
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