Central Line Associated Bloodstream Infections (CLABSI) - Documentation

Please explain the documentation icons for NPSG.07.04.01 EPs 6 and 12. What will surveyors expect to see?

NPSG.07.04.01 EP 6 requires use of "a catheter checklist and a standardized protocol for central venous catheter insertion" The checklist or protocol is not required to be a part of the patient's medical record. A simple indication that the checklist or protocol was completed, perhaps via a checkbox or brief note, is sufficient. NPSG.07.04.01 EP 12 requires use of a "standardized protocol to disinfect catheter hubs and injection ports before accessing the ports". This is not a patient-specific documentation requirement. Surveyors will ask to see each organization's protocol; this may be in the form of a policy, protocol, etc.
Last updated on July 26, 2017
Manual: Ambulatory
Chapter: National Patient Safety Goals NPSG

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