Healthcare PICC Form

PERIPHERALLY INSERTED CENTRAL CATHETER (PICC) ASSESSMENT, CONSENT AND ORDER FORM

Patient Information

Date of Birth:    Medical Record Number:    Gender: Male Female Other

Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance / Billing

Policy Number:    Group Number:    Subscriber Name:

Medical History and Assessment

Anticoagulant / Antiplatelet use within last 7 days:    If yes, specify:

Known bleeding disorder or coagulopathy:    Platelet count:    INR:

PICC Indication, Procedure Details and Orders

Indication for PICC (select all that apply): Long-term IV therapy Total parenteral nutrition Extended IV antibiotics Other

Planned Insertion Date:    Planned Time:    Laterality: Left Right

Catheter size (Fr):    Catheter type:    Number of lumens:

Guidance method: Ultrasound Fluoroscopy Electromagnetic tip confirmation

Pre-Procedure Assessment / Checklist

Vitals: BP    HR    RR    SpO2

Allergies verified:    Informed consent obtained:    Ultrasound available and functioning:

Risks, Benefits, Alternatives and Patient Acknowledgment

I acknowledge that the clinician has explained the procedure of PICC insertion, the intended benefits, and the foreseeable risks including, but not limited to: infection, bleeding, thrombosis, catheter malposition, pneumothorax, vascular injury, need for additional procedures, and allergic reaction to dressings or medications. I understand reasonable alternatives (including peripheral IV access, midline catheter, central venous catheter placed at another site, or no catheter) and the risks and benefits of those alternatives.

I have had the opportunity to ask questions and have had them answered to my satisfaction. I understand that I may withdraw my consent at any time prior to the procedure without affecting my future care.

Patient states they understand the information provided: Yes No

Post-Procedure Orders

Verify catheter tip position with: Chest X-ray Fluoroscopy/Contrast Electromagnetic tip confirmation

Heparin/Saline lock order: Heparin (specify concentration/volume): Saline flush per protocol

HIPAA / Privacy Acknowledgment and Authorization

I acknowledge that my protected health information related to the PICC procedure may be accessed by clinical staff for the purposes of treatment, billing, and quality assurance consistent with applicable law. I authorize release of necessary information to other treating providers and to the billing entity.

This authorization shall expire on:

Clinician Attestation (for chart)

I attest that I have reviewed the patient's medical history, verified allergies and coagulation status, and discussed risks, benefits, and alternatives. I have answered the patient's questions and obtained informed consent.

Final Patient Consent and Signature

By signing below I certify that I am the patient or am authorized to consent on behalf of the patient. I have read (or had read to me) the information above, it was explained in terms I understand, and all of my questions have been answered. I consent to the insertion of a peripherally inserted central catheter (PICC) and to the post-procedure care and verification as ordered above.

If signing on behalf of patient, relationship to patient:

Sign Now