Ultrasound-Guided Vascular Access Procedure Documentation Form
Document key details of the ultrasound-guided vascular access procedure accurately and completely.
Procedure Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Operator's Full Name
*
First Name
Last Name
Role of Operator
*
Please Select
Attending Physician
Resident
Fellow
Nurse Practitioner
Physician Assistant
Other
Site of Vascular Access
*
Please Select
Internal Jugular
Subclavian
Femoral
Peripheral Vein
Other
Type of Vessel Accessed
*
Please Select
Vein
Artery
Other
Type of Catheter or Device Used
*
Please Select
Central Venous Catheter
Dialysis Catheter
Peripheral IV
Arterial Line
Other
Number of Attempts
*
Was Ultrasound Guidance Used Throughout?
*
Yes
No
Complications (if any)
*
None
Arterial Puncture
Hematoma
Pneumothorax
Malposition
Other
Submit Documentation
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