Date:
Time:
Procedure: Triple lumen catheter (TLC) placement
Indications: Pt needs IV access
Patient consent:
Indications and risks explained to the Pt. Pt understands the risks of the
procedure and consents.
Lab tests: CBC- Hgb, Platelets , INR -
Anesthesia: Local w 2% lidocaine
Description of the procedure: Using sterile prep, local anesthesia, standard
position, device and technique a TLC was placed in
Placement successful.
Complications:
Estimated blood loss:
Disposition: Pt tolerated the procedure well.
Signature:
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