Use when the device is functioning and the site is uncomplicated. Fill the bracketed blanks with the visit’s actual device and findings; the clinical findings are not changed — the reasoning a layperson cannot supply is added. The skilled rationale supports the record when it is accurate, individualized, consistent with the plan of care, and tied to the findings, orders, and patient response documented during the actual visit.
Skilled device assessment and care completed for a [device, size, lumens], inserted [date]. Site clean, dry, and intact without erythema, swelling, tenderness, drainage, or bleeding; [patent — flushed without resistance / brisk blood return] [or enteral patency and residual]. Securement intact, external length/marking [unchanged] with no migration. Sterile dressing changed per order and labeled; [drain output / feeding] [amount/character] within expected range and tolerated. Tubing and connections intact, closed system maintained; [infusion/feeding solution, rate, pump] per order. No signs of device-related complication. The sterile assessment and care, with the site and patency evaluated against baseline, confirm the device is functioning and uncomplicated; site care, flushing, and complication signs reinforced with the patient/caregiver, who [teach-back result].
Short form
Skilled device care, [device], inserted [date]: site clean/dry/intact, [patent/blood return]; securement intact, length unchanged; sterile dressing changed per order; [output/feeding] within range; closed system maintained; no complication. Device functioning; site-care and complication-sign teaching reinforced, teach-back correct.
