Assess each line/drain and document the covered procedure and the skilled observation:
For an IV/central line: the site (erythema, swelling, tenderness, drainage), patency and blood return where applicable, the dressing (clean, dry, intact, dated), and securement; the medication/fluid administered and the response.
For a drain: the type, the output volume and character, the site condition, patency, and securement.
Signs of a line/drain complication (infiltration, phlebitis, occlusion, dislodgement) and of a device-associated infection (site or systemic).
MDS-supportive data
IV medications and IV access are coded in MDS Section O0110; IV/anticoagulant medications in Section N; the treated infection/condition in Section I. The record must document the procedure, the site assessment, and the response so Section O is supported.
