INDICATION:_ PROCEDURE OPERATOR: _ ATTENDING PHYSICIAN: _ In Attendance (Y/N)_ Ultrasound Used: Y/N CONSENT:
[_] During the informed consent discussion regarding the procedure, or treatment, I explained the following to the patient/designee:
a. Nature of the procedure or treatment and who will perform the procedure or treatment.
b. Necessity for procedure and the possible benefits.
c. Risks and complications (most common and serious).
d. Alternative treatments and the risks, benefits and side effects of each (including no treatment).
e. Likelihood of the patient achieving his/her goals without this procedure and surgery treatment.
f. Problems that might occur during the recuperation.
g. Conflicts of interest, if any
[_] The procedure was emergent, the patient was unable to provide consent, and a designee was not immediately available. PROCEDURE SUMMARY: The CDC Central Line Insertion Practices form was completed by an independent observer (_) starting with the first handwash prior to starting sterile technique. A time out was performed. My hands were washed immediately prior to the procedure. I wore a surgical cap, mask with protective eyewear, sterile gown and sterile gloves throughout the procedure. The LEFT/ RIGHT inguinal region was prepped using chlorhexidine scrub and draped in sterile fashion using a full drape and sterile probe cover and sterile gel employed. The femoral pulse was identified. Anesthesia was achieved using 1% lidocaine. Palpating the femoral pulse throughout the procedure, the introducer needle was inserted medial to the femoral artery, inferior to the inguinal crease and into the femoral vein. Venous blood was withdrawn. The syringe was removed and a guidewire was advanced into the introducer needle. A small incision was made at the skin surface with a scalpel and the introducer needle was exchanged for a dilator over the guidewire. After appropriate dilation was obtained, the dilator was exchanged over the wire for a _ central venous catheter. The wire was removed and the catheter was sutured in place at _ cm. A sterile sorbaview shield was placed over the catheter at the insertion site. The patient tolerated the procedure without any hemodynamic compromise. At time of procedure completion, all ports aspirated and flushed properly. Estimated blood loss is _.