PICC Line Removal Checklist Form
Complete this checklist to ensure all required steps are followed for safe and effective PICC line removal.
Patient identity confirmed (using two identifiers)
*
Yes
No
Medical order for PICC line removal verified
*
Yes
No
Allergies reviewed (latex, antiseptics, adhesives)
*
No known allergies
Allergies present (specify below)
If allergies present, specify:
Hand hygiene performed before procedure
*
Yes
No
All necessary equipment prepared and within reach
*
Sterile gloves
Gauze and dressing supplies
Antiseptic solution
Waste disposal supplies
Patient positioned appropriately (supine or per protocol)
*
Yes
No
Insertion site assessed for signs of infection or complications
*
No signs of infection/complication
Signs present (specify below)
If signs present, specify:
Hemostasis achieved and site dressed post-removal
*
Yes
No
Submit Checklist
Should be Empty: