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1. Date

Date
Time

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2. Unit/Room Number

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3. Line Type

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4. Is the dressing (preferably chlorhexidine gluconate or CHG –based) intact over the catheter insertion site: does the dressing form a seal along all edges and not visibly soiled)?

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5. Is the dressing dated and timed/changed according to facility policy?

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6. Is the catheter secured to reduce movement or tension?

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7. Are the administration tubing sets labeled and within the date range according to facility policy?

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8. Are all inactive ports capped according to facility policy?

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9. Was HH performed properly?

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10. Was the hub scrubbed According to policy/IFU?

T