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What you chart every shift

IV infiltration and extravasation: what to chart

Years from now someone reads your infiltration note. Make it say what you saw, what you did, and who you told.

9 min read built on 6 full opinions updated 2026-09-24

Written by a med-surg RN, ten years, day shift. Why there is no name on it

Denise reacting to this topic

An IV has gone bad. Maybe it was saline. Maybe it was something that burns tissue: norepinephrine, potassium, TPN, phenytoin, contrast. You've stopped the infusion and pulled the line. Now you chart it, and years from now someone may read that note to find out what you saw, when you saw it, and what you did.

The short version

  • Chart what you see and measure. Site, catheter size, what was running, the rate, a rough estimate of how much leaked, the size of the swelling in cm, skin color and temperature, cap refill, and what the patient says.
  • Chart what you did and when. Stopped the infusion, aspirated (if your policy says to), removed the catheter, elevated the limb, put on a warm or cold compress per policy, gave an antidote if ordered. Put a time on every step.
  • Chart who you told. Provider's name, the time you called, what they ordered. MD aware gives none of that.
  • Every time you give a drug, chart which line it went into. This matters most when the patient has more than one.
  • Chart the follow-up. Recheck the site, measure again, compare with the first numbers.

What goes wrong

Usually the problem isn't a missing note. It's a note that says nothing: site c/d/i copied forward every hour, or IV infiltrated, removed and that's it.

Nobody can go back and look at that arm later. The chart is all that's left. So every question gets answered from the chart, or from somebody's memory:

  • When did it start? If your last entry is just c/d/i, nobody can tell whether you looked, pressed on the site, or compared it with the other arm.
  • Which line? Four IVs, and the note says phenytoin given IV. Years later people are piecing it together from memory.
  • How bad was it? Swelling noted could be 1 cm or 10 cm. And you have nothing to compare against at the next check.
  • What did you do about it? If the stop, the aspiration and the call aren't charted, the record doesn't show they happened.

Infiltrations happen even with good care. A clear note shows two things: a real check found the site normal, and when it changed, someone noticed and acted.

It is not hypothetical

Moton v. Emory Healthcare, Inc. (Court of Appeals of Georgia, 2025) https://www.courtlistener.com/opinion/10686238/georgia-moton-v-emory-healthcare-inc/

The patient had four IV lines, one of them in the hand and one in the neck. She got two doses of phenytoin while sedated. Later her hand became necrotic and was amputated. The opinion states: "Medical staff did not document through which IV the medication was administered". Four years later, one nurse testified she used the jugular line. But Emory's own representative had said earlier that neither nurse independently remembered which line she used. The trial court granted summary judgment for the hospital. The appeals court reversed, pointing to the conflict between those two accounts. So the case goes forward. That's not a finding that the nurses did anything wrong. What it does show: one line in the chart naming the IV would have answered a question memory couldn't.

Scottman v. Emory Healthcare, Inc. (Court of Appeals of Georgia, 2025) https://www.courtlistener.com/opinion/10606290/mike-scottman-v-emory-healthcare-inc/

Here it went the other way. A NICU infant had TPN and lipids running through a forearm IV and ended up with full-thickness burns. The suit claimed the nurse skipped hourly checks. The nursing notes had checks at 0600 and 0700 with the site recorded as "dry and intact", and the trial court found the records showed the checks happened. The appeals court affirmed, partly because of procedural problems with the plaintiffs' expert affidavits. Look at what the court did not decide: whether those checks were good enough. The plaintiffs' fallback argument was that a normal check an hour before a severe burn means someone missed the infiltration. The stock phrase proved a check happened. It said little about what the nurse saw. One more detail. The wound photos in the record appear to have been taken on a provider's personal phone, and the court noted nothing showed they were ever part of the medical record.

Bean v. St. Francis Hospital (Supreme Court of Oklahoma, 2026) https://www.courtlistener.com/opinion/10849078/bean-v-st-francis-hospital/

Contrast infiltrated from a hand IV during a CT. Among other criticisms, the patient's nursing expert said the CT techs breached the standard of care by "failing to document that they aspirated for blood return before injecting the contrast". The court decided the case on other grounds: the nurse expert wasn't qualified to testify about the physicians, and causation wasn't established. It never ruled on the documentation point. Still, that's the kind of question a reviewer asks: did you check blood return, and does the chart say so?

Estate of Northrop v. Hutto (Mississippi Supreme Court, 2009) https://www.courtlistener.com/opinion/1646062/estate-of-northrop-v-hutto/

A peripheral IV extravasated under a warming blanket during a three-hour surgery. The patient needed a fasciotomy and a skin graft. The court reinstated summary judgment for the defense, because the plaintiff's expert didn't set out an objective standard of care. Under questioning, the expert agreed: "The extravasation, per se, is not proof of negligence". Keep that in mind if you're reading how much trouble am I in threads. An infiltration by itself doesn't prove anyone did anything wrong. People look at the record of what was monitored and what was done.

What to write instead

How it often gets charted What would have been better
0600 IV site c/d/i.0600 L forearm 22g PIV: no swelling, no redness, no leaking, skin warm and soft, compared to R arm. Dressing intact. Flushes without resistance. TPN at 4 mL/hr and lipids at 0.5 mL/hr via pump, pressure within range.
2200 IV infiltrated. Removed. MD aware.2200 L forearm 20g PIV: swelling approx 4 x 5 cm, skin cool, taut, blanched. Pt reports tightness, pain 4/10. NS at 100 mL/hr; est. 50 mL infiltrated since 2100 check (site soft, no edema at 2100). Infusion stopped 2202. Catheter removed, tip intact. Arm elevated on pillow. Radial pulse 2+, cap refill <3 sec, fingers warm, sensation intact. Dr. Patel notified 2210; no new orders.
Levo extravasated, MD notified, antidote given.1415 R hand PIV 20g: blanching and swelling approx 3 x 3 cm at insertion site, cool to touch. Norepinephrine 8 mcg/min infusing. Infusion stopped 1416. Aspirated approx 1 mL via catheter per extravasation policy, then catheter removed. Site outlined with skin marker, time written. Dr. Ruiz notified 1418. Phentolamine given 1440 by Dr. Ruiz per order. Pressor restarted via L IJ CVC 1425, placement confirmed per CXR 1300.
Dilantin 1 g IV given.0930 Phenytoin 1 g IV in NS 100 mL given via L IJ CVC, distal lumen. Blood return confirmed before start. L hand and L wrist PIVs not used. Site checked at 15 min: no swelling.
Site looks better.0200 L forearm former PIV site: swelling now approx 2 x 3 cm (was 4 x 5 cm at 2200), soft, skin pink, no blistering. Cap refill <3 sec, moves all fingers, sensation intact. Pt reports pain 1/10. Photo taken with unit camera per policy and uploaded to chart.
Pt pulled at IV, site infiltrated.2330 Pt found with tape lifted and catheter partially out of L AC. Site swollen approx 2 x 2 cm. Infusion stopped 2331, catheter removed.

Every good version has the site, the device, what was running, the numbers, what you did and when, who you told. And a baseline for the next check.

Words that do the damage

Word or phrase Why it hurts Use instead
c/d/i charted by reflexDoesn't show you looked, felt the site, or compared armsWhat you actually checked: no swelling, soft, warm, flushes easily, blood return
WNLNormal compared with what?The specific findings
slight swelling, some rednessCan't be measured or tracked over timeSize in cm, compared with the other limb
infiltrated with nothing after itNo fluid, no volume, no time, no severityWhat was running, rate, estimated volume, measurements, grade per facility scale
MD awareWho, when, and what they said is missingProvider name, time of call, orders received or no new orders
tolerated wellTells nobody anything about the siteSite findings at the check
pt pulled at IV, pt noncompliantReads as blame, and you usually didn't see it happenWhat you found: tape lifted, catheter partly out
my error, should have caught, accidentallyThe chart is for findings, not judgments. Reviews and debriefs are where you talk about what went wrongFacts and times only
IV with no site on a med entryWith several lines, nobody can tell which oneLine and lumen: via L IJ CVC distal, via R hand 22g PIV

What the guidance says

  • Use the right name. A nonvesicant leaking into tissue is an infiltration. A vesicant is an extravasation. Put the right word in the note; it tells the next reader how serious the injury may be. (AJN via Ovid, IVWatch)
  • Check blood return before you give the drug. No blood return means the line is questionable. Chart that you checked. (Cleveland Clinic Journal of Medicine, MD Anderson)
  • When you can, don't put peripheral IVs over joints, and keep high-risk infusions out of the hand and the antecubital fossa. Chart the exact site so the next person knows what they're looking at. (Cleveland Clinic Journal of Medicine, Apex Nursing)

Copy this

Chart note: when you find it

`` [DATE] [TIME] Site: [LOCATION, e.g. L dorsal forearm] [GAUGE] PIV, inserted [INSERT DATE]. Infusing: [DRUG/FLUID AND CONCENTRATION] at [RATE] via [PUMP / GRAVITY]. Last site check: [TIME OF LAST CHECK] - [FINDINGS AT LAST CHECK]. Findings now: swelling approx [LENGTH] x [WIDTH] cm. Skin [COLOR], [COOL/WARM], [SOFT/FIRM/TAUT]. [BLISTERING: YES/NO]. [LEAKING AT SITE: YES/NO]. Compared to opposite limb: [FINDINGS]. Distal to site: pulse [GRADE], cap refill [SECONDS] sec, fingers/toes [WARM/COOL], sensation [INTACT/DECREASED], movement [FULL/LIMITED]. Pt reports: [PATIENT'S WORDS, e.g. burning at site, pain 6/10]. Estimated volume infiltrated: [VOLUME] mL. Grade per facility scale: [GRADE]. Actions: [TIME] infusion stopped. [TIME] [ASPIRATED APPROX ___ mL VIA CATHETER PER POLICY / NOT INDICATED PER POLICY]. [TIME] catheter removed, tip [INTACT/NOT INTACT]. [TIME] site border outlined with skin marker, time written on skin. [TIME] limb elevated on [PILLOW/SLING]. [TIME] [WARM/COLD] compress applied per [POLICY NAME / ORDER], for [DURATION]. [TIME] [PROVIDER NAME, ROLE] notified by [PHONE/IN PERSON]. Orders: [ORDERS OR NO NEW ORDERS]. [TIME] [ANTIDOTE NAME, DOSE, ROUTE] given by [NAME] per order. [TIME] photo taken with [FACILITY CAMERA/APP] per policy, uploaded to chart. Infusion resumed via [NEW SITE / LINE] at [TIME]. Plan: reassess site every [INTERVAL] per [POLICY/ORDER]. [YOUR NAME, CREDENTIALS] ``

Chart note: follow-up check

`` [DATE] [TIME] Former PIV site [LOCATION]: swelling approx [LENGTH] x [WIDTH] cm (was [PREVIOUS SIZE] at [PREVIOUS TIME]). Within / beyond marked border: [WITHIN/BEYOND]. Skin [COLOR], [TEMPERATURE], [SOFT/FIRM]. Blistering: [YES/NO]. Drainage: [NONE / DESCRIBE]. Distal: pulse [GRADE], cap refill [SECONDS] sec, sensation [FINDINGS], movement [FINDINGS]. Pt reports pain [SCORE]/10 at site. Interventions continued: [ELEVATION / COMPRESS / NONE]. [PROVIDER NAME] updated at [TIME]: [RESPONSE / NOT NEEDED - NO CHANGE]. [YOUR NAME, CREDENTIALS] ``

Medication entry: which line, every time

`` [DATE] [TIME] [DRUG] [DOSE] in [DILUENT AND VOLUME] via [LINE AND LUMEN, e.g. L IJ CVC distal lumen]. Blood return confirmed before administration: [YES/NO - IF NO, ACTION TAKEN]. Other lines present and not used: [LIST]. Site checked at [TIME DURING/AFTER]: [FINDINGS]. [YOUR NAME, CREDENTIALS] ``

Message to provider (SBAR)

`` S: This is [YOUR NAME], RN on [UNIT], calling about [PATIENT NAME], room [ROOM], [DOB/MRN]. [His/Her/Their] [LOCATION] PIV has [INFILTRATED/EXTRAVASATED] with [DRUG/FLUID]. B: Infusing at [RATE] since [TIME]. Last normal site check at [TIME]. A: Swelling approx [SIZE] cm, skin [FINDINGS], pain [SCORE]/10, cap refill [SECONDS] sec, sensation [FINDINGS]. Estimated [VOLUME] mL. Infusion stopped at [TIME], catheter removed at [TIME]. R: Per our policy, [DRUG] extravasation calls for [POLICY ACTION]. Do you want [ANTIDOTE / COMPRESS TYPE / CONSULT / NEW ACCESS]? Where do you want [DRUG] resumed? ``

Incident report (facility safety report)

`` Date/time discovered: [DATE] [TIME] Patient: [NAME / MRN], [UNIT], [ROOM] Device: [GAUGE] PIV, [LOCATION], inserted [DATE] by [NAME IF KNOWN] Infusing: [DRUG/FLUID], [CONCENTRATION], [RATE], via [PUMP MODEL / GRAVITY] Last documented site check before discovery: [TIME], findings [FINDINGS] What was found: [SIZE OF SWELLING, SKIN FINDINGS, PATIENT COMPLAINT] Estimated volume: [VOLUME] mL Actions taken and times: [STOP TIME], [ASPIRATION], [REMOVAL TIME], [ELEVATION], [COMPRESS], [ANTIDOTE AND TIME] Provider notified: [NAME, ROLE, TIME] Charge nurse / supervisor notified: [NAME, TIME] Patient / family informed: [NAME, TIME, BY WHOM] Photo: [TAKEN WITH FACILITY SYSTEM AT TIME / NOT TAKEN] Current status: [SITE FINDINGS AT TIME OF REPORT] Reported by: [YOUR NAME, CREDENTIALS], [DATE] [TIME] ``

If you remember one thing

Write down where it is, what was running, how big it is, what you did and when, and who you told. And name the line on every drug entry.

Read the decisions yourself

Every case below is a published decision on CourtListener. Open them. Nothing on this page asks you to take our word for what a court said — and where we only had the search result rather than the full opinion, it says so.

All the decisions behind this guide, in one page — searchable by court, year, or what happened.

What people say on the floor

Nurses talking to each other about this, quoted as they wrote it. This is opinion, not a source. It is here because it shows what the argument actually is — the rules above come from the decisions and the published guidance, not from these threads.

  • We have a nursing policy that lists certain vesicants and what to do (cold compress, warm compress, elevate, Vytrase, antidotes, etc.). If it isn’t on that list, typically you just chart the site and continue monitoring it and continue to document on it until it returns to normal. ... step 4: admini

    r/nursing on Reddit: When a peripheral IV infiltrates, what do you do? reddit

  • Huge difference between something like NS vs levophed. Having an infiltration so bad it required surgery is bad. ... We had a patient almost lose a hand because someone ran a whole bag of vanco into a bad iv. Fasciotomy and everything. Now we have to chart an iv assessment every hour on anything scl

    r/nursing on Reddit: IV infiltration…how much trouble am I in? reddit

  • A loose catheter under tegaderm, fully scabbed and healed extravasation point. If you’re not doing it, don’t chart it. If the blank bothers you chart saline locked and call it good. ... I worked with an older nurse that would report an IV but wouldn't flush it or anything. She would only assess

    r/nursing on Reddit: Flush Your IVs reddit

  • Because I’m the IV nurse and I have to keep track of where y’all are infiltrating various things ... So they can properly chart and assess the IV and the site.

    r/nursing on Reddit: Why do some nurse care which arm the piv is on? reddit

What everyone else says

Guidance from professional bodies, insurers and other people who write about this. Useful, but it is advice, not law — that part is above.

How would you chart it?

This is the part we cannot research. If you have a way of writing this that has held up — put it here. No account, no name needed. Nothing that could identify a patient: no room numbers, no dates of birth, no MRNs. Use placeholders, the example still works.

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