PICC Line Outcomes Evaluation Form
Please complete this form to assess patient outcomes related to PICC line use.
Date of PICC Line Insertion
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Indication for PICC Line Placement
*
IV antibiotics
Parenteral nutrition
Chemotherapy
Difficult venous access
Other
Was the PICC line removed during this admission?
*
Yes
No
Reason for PICC Line Removal
*
Completion of therapy
Complication
Patient request
Other
Complications Observed (select all that apply)
*
None
Infection
Thrombosis
Catheter occlusion
Mechanical complication
Other
Signs of Local Infection at Insertion Site
*
None
Redness
Swelling
Discharge
Pain
Duration of PICC Line Use (days)
*
Patient Symptoms Related to PICC Line
*
Fever
Chills
Pain at site
None
Other
Overall Outcome of PICC Line Use
*
1
2
3
4
5
Additional Comments
Submit Evaluation
Should be Empty: