Please explain the documentation icons for EPs 10 and 16. What will surveyors expect to see?
A. EP 10 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. EP 16 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.
