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LPN IV Series: Legalities, Infection Control, Safe Injection and Documentation

3 Contact Hours
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This peer reviewed course is applicable for the following professions:
Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN)
This course will be updated or discontinued on or before Friday, March 21, 2025

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.

This course does not meet the Florida LPN IV Certification requirement.

≥ 92% of participants will know IV legalities, infection control, safe injection, and documentation.


After completing this continuing education course, the participant will be able to meet the following objectives:

  1. Determine the correct scope of LPN IV therapy practice.
  2. Identify correct infection control practices when starting and maintaining IV therapy.
  3. Summarize occupational blood exposure prevention methods.
  4. Evaluate post-exposure follow-up for HIV and hepatitis B.
  5. Outline appropriate documentation practices for IV therapy.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Last Updated:
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Authors:    Desiree Reinken (MSN, APRN, NP-C) , Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)


It is not uncommon for licensed practical nurses (LPNs) to have the authority to perform intravenous (IV) therapy. Fluid and medication therapy, nutritional administration, and the establishment of an IV access are prevalent tasks and often necessary in many healthcare settings. The responsibility of IV therapy should not be taken lightly, as it is a service to be performed when giving optimal care to our patients. Suboptimal performance with IV therapy, including practicing out of scope and incorrect documentation, can lead to poor patient outcomes and legal challenges.

Every healthcare facility has IV therapy policies that outline IV practices and are dependent upon the type of care being provided. These policies are required to obtain accreditation. The facility policy is often developed based on local, state, and national standards. However, these policies cannot go beyond what the state's nurse practice act (NPA) permits.

The legalities of IV practice in the state of Florida are discussed in this course. However, the content discussed in this course may not be the standard for other states and other facilities. Please check your own state's rules and regulations, including the NPA, regarding IV therapy by LPNs.


“Under the direction of a registered nurse (RN)” means that the RN has delegated IV therapy functions. The RN does not always have to be on the premises for IV therapy to occur.

“Direct supervision” means the RN, physician, or dentist has to be on the premises and immediately physically available (Florida Administrative Code [FAC], 2015).

Florida Nurse Practice Act and LPN IV Therapy

The following are outlined in Florida’s NPA. An NPA is designed to protect patients and healthcare workers by outlining and regulating education and the scope of practice (Huynh and Haddad, 2022).

No IV Course or Facility Approval

LPNs who have not completed the specified IV course can perform with a limited scope of practice that includes the calculation and adjustment of flow rate, observation and reporting subjective and objective signs of adverse reactions to IV administration, inspecting the insertion site, changing the dressing, discontinuing IVs from peripheral veins, and hanging bags of hydrating fluid. These actions have to be done under the direction of an RN, physician, or dentist (FAC, 2015).

Completed Course and Facility Approval

An LPN can be more involved in IV therapy if they have completed an approved course with a return demonstration and are approved by a facility. Administration of IV therapy involves infusion or injection through a peripheral venous system. IV therapy includes observing, initiating, monitoring, discontinuing, maintaining, regulating, adjusting, documenting, planning, intervening, and evaluating. LPNs work under the direction of an RN who has delegated IV functions. The RN does not always have to be in the facility for delegated functions. Tasks that are in the scope of practice for LPNs include the following:

  • insert a peripheral IV
  • remove IV catheters
  • set up and use IV pumps
  • maintain an IV site
  • administer IV fluids and medications
  • accurately assess an IV site
  • respond to complications of IV therapy

An LPN can perform certain aspects of IV therapy via central lines after appropriate education and training (FAC, 2015).

Competency and Knowledge Requirements

The following is outlined under the Florida Administrative Code and Registrar and considered to be the standards for competency and knowledge requirements for IV therapy.

  • Contents. The board endorses the IV Course Guidelines issued by the Education Department of the National Federation of LPNs in November 1983. The IV therapy education must contain the following components:
    • Policies and procedures of the NPA and the employing agency regarding IV therapy, including the legalities of the LPN role and the administration of safe care. Principles of charting are also included.
    • Psychological preparation and support for the patient receiving IV therapy and the appropriate family members/significant others.
    • Site and function of the peripheral veins used for venipuncture.
    • Procedure for venipuncture, including physical and psychological preparation, site selection, skin preparation, palpation of veins, and collection of equipment.
    • Relationship between IV therapy and the body's homeostatic and regulatory functions, with attention to the clinical manifestations of fluid and electrolyte imbalance.
    • Signs and symptoms of local and systemic complications in the delivery of fluids and medications and the preventive and treatment measures for these complications.
    • Identification of various types of equipment used in administering IV therapy with content related to criteria for each use and means of troubleshooting for malfunction.
    • Formulas used to calculate fluid and drug administration rates.
    • Methods of administering drugs intravenously and advantages and disadvantages of each.
    • Principles of compatibility and incompatibility of drugs and solutions.
    • Nursing management of the patient receiving drug therapy, including principles of chemotherapy, protocols, actions, and side effects.
    • Nursing management of the patient receiving blood and blood components, following institutional protocol. Include indications and contraindications for use and the identification of adverse reactions.
    • Nursing management of the patient receiving parenteral nutrition, including principles of metabolism, potential complications, and physical and psychological measures to ensure the desired therapeutic effect.
    • Principles of infection control in IV therapy, including aseptic technique and prevention and treatment of iatrogenic infection.
    • Nursing management of special IV therapy procedures commonly used in the clinical setting, such as heparin lock, central lines, and arterial lines.
    • Glossary of common terminology pertinent to IV fluid therapy.
    • Performance checklist to evaluate the clinical application of knowledge and skills (FAC, 2010).
  • Central Lines. The board recognizes that through appropriate education and training, an LPN can perform IV therapy via central lines under the direction of an RN. Appropriate education and training require a minimum of four hours of instruction. The required four hours of instruction may be included in the 30 hours required for IV therapy education. The necessary education and training, at a minimum, shall consist of didactic and clinical practicum instruction in the following areas:
    • central venous anatomy and physiology
    • central line site assessment
    • central line dressing and cap changes
    • flushing of the central line
    • medication and fluid administration via the central line
    • central line blood drawing
    • central line complications and remedial measures (FAC, 2010)
  • Upon completion of the IV therapy training via central lines, the LPN shall be assessed on theoretical knowledge, practice, clinical practice, and competence. The clinical practice assessment must be witnessed by an RN who shall file a proficiency statement regarding the LPN’s ability to perform IV therapy via central lines. The proficiency statement shall be kept in the LPN’s personnel file (FAC, 2010).
  • Providers: The LPN/IV education must be sponsored by a provider of continuing education courses approved by the board. To be qualified to teach any such course, the instructor must be a current licensed RN in good standing in this state, have teaching experience, and have professional nursing experience, including IV therapy. The provider will be responsible for issuing a certificate verifying the completion of the required hours and course content (FAC, 2010).
  • Educational Alternatives. The cognitive training shall include one or more of the following:
    • Post-graduate Level Course. In recognition that the curriculum requirements mandated for practical nursing programs are extensive and that not every LPN will administer IV therapy, the course necessary to qualify an LPN or graduate practical nurse to administer IV therapy shall be not less than a 30-hour post-graduate level course teaching aspects of IV therapy.
    • Credit for Previous Education. The continuing education provider may credit the LPN or graduate practical nurse for previous IV therapy education on a post-graduate level, providing each component of the course content is tested by, and competency demonstrated to the provider.
    • Nontraditional Education. Continuing education providers may select nontraditional education alternatives to acquire cognitive content. Such alternatives include:
      1. Interactive videos,
      2. Self-study,
      3. Other nontraditional education that may be submitted to the board for consideration and possible approval. Any continuing education providers using nontraditional education must make provisions to demonstrate and verify knowledge (FAC, 2010).
  • Clinical Competence. The course must be followed by supervised clinical practice in IV therapy to demonstrate clinical competence. Verification of clinical competence shall be the responsibility of each institution employing an LPN based on institutional protocol. Such verification shall be given through a signed statement of a Florida-licensed RN (FAC, 2010).

Outside the LPN Scope of Practice

Aspects of IV therapy that are outside the scope of practice of the LPN unless, under the direct supervision of the RN, physician, or dentist include the following:

  • initiation of blood and blood products
  • initiation or administration of cancer chemotherapy
  • initiation of plasma expanders
  • initiation or administration of investigational drugs
  • mixing IV solution
  • IV pushes, except heparin flushes and saline flushes (FAC, 2015)

Infection Control

Now that the Florida scope of practice for LPN IV therapy has been defined and the coinciding requirements have been listed, it is time to discuss infection control.

IV therapy is an invasive procedure. A strict aseptic technique for initiating venipuncture, its care, and site maintenance is necessary to prevent the transmission of bloodborne pathogens. Bloodborne pathogens are any pathogenic microorganisms found in the blood or other bodily infectious material that can cause human disease. Examples of bloodborne pathogens include hepatitis B virus, hepatitis C virus, human immunodeficiency virus (HIV), malaria, syphilis, viral hemorrhagic fever, arboviral infections, Creutzfeldt-Jakob disease, and relapsing fever. The three bloodborne pathogens most commonly involved in occupational exposures in healthcare workers are hepatitis B, hepatitis C, and HIV (Occupational Safety and Health Administration [OSHA], 2001).

Exposure to a bloodborne pathogen can occur through:

  1. A percutaneous injury, such as a needlestick or a laceration from a sharp object.
  2. Contact of a mucous membrane or non-intact skin (i.e., skin that is abraded, chapped, or has dermatitis) with blood, tissue, or other body fluids that are potentially infectious.
  3. Direct contact (the healthcare worker was not using barrier protection) with concentrated HIV, hepatitis B, or hepatitis C.

Exposures can occur through needlesticks or cuts from other sharp instruments contaminated with an infected patient's blood or through contact of the eye, nose, mouth, or skin with a patient's blood. Percutaneous injuries and splash exposures appear to be equally involved, and the most common cause of a percutaneous injury is often due to puncture wounds from hollow-bore needles. LPNs should adhere to federal and state requirements that protect healthcare personnel from exposure to bloodborne pathogens.

Factors that may determine the overall risk for occupational transmission of a bloodborne pathogen include:

  • the number of infected individuals in the patient population
  • the chance of becoming infected after a single blood contact with an infected patient
  • the type and number of blood contacts

Most exposures do not result in infection; however, it is always best to follow exposure precaution and prevention steps. Following a specific exposure, the risk of infection may vary with factors such as these:

  • the pathogen involved
  • the depth of the injury
  • the location of the needle (artery or vein)
  • type of sharps instrument (hollow bore needle or scalpel)
  • visible contamination with blood
  • the amount of blood involved in the exposure
  • the amount of virus in the patient's blood at the time of exposure

It is important to note that the risk of infection is very low if the source's viral load is undetectable, but there is still a risk (OSHA, 2001).

Catheter-Related Bloodstream Infections

Infection control is crucial when inserting any type of catheter. Not only are LPNs at risk of occupational exposure, but we also put our patients at risk of serious infections and complications if we do not maintain clean or aseptic technique. Maintaining proper technique when initiating and maintaining IV therapy is essential to prevent infections.

Catheter-related bloodstream infections (CRBSI) arise from bacteria in the IV catheter. Almost 30% of nosocomial or hospital-acquired infections are caused by an IV catheter, whether through a peripheral IV or a central line (Ruiz-Giardin et al., 2019). Up to 25% of patients diagnosed with CRBSI will succumb to the illness (Serane and Kothendaraman, 2016;). CRBSIs are preventable and avoidable if the proper steps are taken. Another preventable nosocomial or hospital-acquired infection is central line-associated bloodstream infection (CLABSI). Annually, nearly 15% of patients diagnosed with a CLABSI will die (Toor et al., 2022).

Symptoms associated with CRBSI and CLABSI that LPNs may notice include:

  • fever
  • chills
  • redness and pain around the insertion site
  • discharge (can be non-purulent or purulent)

A more serious infection that may spread to other parts of the body via the bloodstream will have more severe symptoms, such as hypotension, trouble breathing, and a comatose state (Moriyama et al., 2022).

There are certain steps that should be followed to help prevent these infections from occurring, and they include the following:

  • Hand hygiene should be performed before any procedures. Handwashing protects the patient against infection via harmful germs, including their germs, entering their body (Centers for Disease Control and Prevention [CDC], 2019).
  • An aseptic technique should be adhered to for central line maintenance and care. An aseptic technique requires barriers to prevent the transfer of microorganisms from the LPN and the environment to the patient during a procedure. Barriers or PPE include sterile gloves, gowns, drapes, and masks. Environmental controls should also be considered. The doors, when possible, should be closed during procedures.
  • The best insertion site should be chosen with caution. For peripheral catheters, an upper extremity should be used (CDC, 2011a).
  • The insertion site should be prepped according to the type of access being inserted. >0.5% chlorhexidine with alcohol is often recommended (CDC, 2019).

Prevention of Exposure

Now that we know why we must adhere to infection control precautions and standards, it is time to discuss how to do so. Avoiding occupational blood exposure is the primary way to prevent transmission of the hepatitis B virus, hepatitis C virus, and HIV in healthcare settings. If exposed, immunization and postexposure management are integral components of a complete program to prevent infection and are important elements of workplace safety.

Controls are incorporated into the healthcare work setting to avoid or reduce exposure to potentially infectious materials. Healthcare-associated transmission is the transmission of microorganisms that is likely to occur in a healthcare setting that can be reduced by using engineered controls, safe injection practices, and safe work practices. Engineered controls are equipment, devices, or instruments that remove or isolate a hazard. Safe injection practices are equipment and practices that allow the performance of injections in an optimally safe manner for patients, healthcare providers, and others that reduce exposure to occupational hazards. Work practice controls are practices and procedures to reduce or eliminate risks (CDC, 2011b).

An example of engineered controls is sharps boxes that are used so staff do not get stuck by blood-contaminated needles or blades. Using IV needles that easily self-cap to avoid needle sticks is an example of a safe injection practice. An example of work practice controls is using a waterproof pad under the patient's arm when starting an IV to retain and dispose of spilled blood.

Nurses, including LPNs, sustain the largest proportion of sharps injuries of all healthcare professionals, but laboratory staff, physicians, housekeepers, and other healthcare professionals do get injured. Some of these injuries expose professionals to bloodborne pathogens that can cause infection. The most common of these pathogens are hepatitis B, hepatitis C, and HIV, which are potentially life-threatening and preventable (OSHA, 2001).

Percutaneous injuries can be avoided by eliminating the unnecessary use of needles, using devices with safety features, and promoting education and safe work practices for handling needles and related systems. Since 1993, the use of safety-engineered sharps devices has increased while conventional sharps devices have decreased. Percutaneous injury rates have decreased dramatically, and many studies have proven that using safety-engineered devices has significantly reduced the number of needlestick injuries. Several sources have identified the desirable characteristics of safety devices. These characteristics include the following:

  • The device is needleless.
  • The safety feature is an integral part of the device.
  • The device preferably works passively (i.e., it requires no activation by the user). If user activation is necessary, the safety feature can be engaged with a single-handed technique, allowing the professional's hands to remain behind the exposed sharp.
  • The user can easily tell whether the safety feature is activated.
  • The safety feature cannot be deactivated and remains protective through disposal.
  • The device performs reliably.
  • The device is easy to use and practical.
  • The device is safe and effective for patient care.

Although each of these characteristics is desirable, some are not feasible, applicable, or available for certain healthcare situations. For example, needles will always be necessary when alternatives for skin penetration are unavailable. Also, a safety feature that requires activation by the user might be preferable to one that is passive in some cases. Each device must be considered on its own merit and ultimately on its ability to reduce workplace injuries. The desirable characteristics listed here should serve only as a device design and selection guideline.

Needles should NEVER be recapped, bent, or broken and should also not be removed from contaminated syringes. Recapping by hand is prohibited under the OSHA bloodborne pathogens standard unless no alternative exists. Sharps should be disposed into a puncture-proof container (OSHA, 2001).

There is an increased risk for exposure via percutaneous injuries, especially where there is:

  • poor visualization
  • blind suturing
  • non-dominant hand opposing or next to a sharp
  • exposure to bone spicules and metal fragments

Sharps equipment should be disassembled using forceps or other devices. Suturing should always be done with a needle holder, forceps, or other tools. Do not use fingers to hold tissue when suturing or cutting. Never leave sharps on a work field. If used needles or other sharps are left in the work area or are discarded in a sharps container that is not puncture-resistant, a needlestick injury may result. Injury may occur when a healthcare professional attempts to transfer blood or other body fluids from a syringe to a specimen container (such as a vacuum tube) and misses the target (Alfulayw et al., 2021).

Safe injection practice in hospitals is well established. However, outbreaks of infections with hepatitis B and hepatitis C amongst patients have been traced back to ambulatory care facilities and associated with non-compliance with safe injection practices, identifying the need to define and reinforce safe injection practices in outpatient care settings. Reusing needles, multidose vials, and work areas containing sterile and contaminated injection supplies contribute to the problem. There has been a lack of understanding of aseptic technique, a lack of oversight, and a failure to follow up on infection control breaches. The following are safe injection practices that apply to the use of needles, cannulas that replace needles, and, where applicable, IV delivery systems.

  • Use an aseptic technique to avoid contamination of sterile injection equipment. Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulas, and syringes are sterile, single-use items; they should not be reused for another patient or access a medication or solution that might be used for a subsequent patient (CDC, 2011b).
  • Use fluid infusion and administration sets (i.e., IV bags, tubing, and connectors) for one patient and dispose of them appropriately after use. Consider a syringe or needle/cannula contaminated once used to enter or connect to a patient's IV infusion bag or administration set. Use single-dose vials for parenteral medications whenever possible. Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use.
  • If multidose vials must be used, the needle, cannula, and syringe used to access the multidose vial must be sterile. Do not keep multidose vials in the immediate patient treatment area and store them following the manufacturer's recommendations; discard them if sterility is compromised or questionable. Do not use bags or bottles of IV solution as a common supply source for multiple patients (CDC, 2011b).


Employers must establish exposure control plans that include post-exposure follow-up. LPNs and other employees must comply with incident reporting requirements mandated by the OSHA bloodborne pathogen standard. Access to clinicians who can provide post-exposure care should be available during all working hours, including nights and weekends. Hepatitis B immune globulin (HBIG), hepatitis B vaccine, and antiretroviral agents for HIV post-exposure prophylaxis (PEP) should be available for timely administration, either by providing access on-site or by creating linkages with other facilities or providers to make them available off-site.

If exposure does occur, provide immediate care to the exposure site, including the following steps:

  • Wash wounds and skin with soap and water.
  • Flush mucous membranes with water.
  • Irrigate eyes with clean water, saline, or sterile irrigants.

No scientific evidence shows that using antiseptics or squeezing the wound will reduce the risk of transmission of a bloodborne pathogen. Using a caustic agent such as bleach is not recommended as it may do further harm. Report the exposure to the government agency responsible for managing exposures. Usually, one person in a facility is appointed responsible for this reporting (CDC, 2021). Reporting is necessary as PEP treatment may be recommended as soon as possible.

Hepatitis B Post-Exposure

Post-exposure care for hepatitis B is dependent upon the source's status. LPNs with written documentation of a complete hepatitis B vaccine series but who have not received postvaccination testing should receive a single vaccine booster dose. LPNs who have received only part of the hepatitis B series should receive the appropriate dose of HBIG and complete the vaccine series. LPNs who have not received any of the hepatitis B vaccine series should receive both HBIG and hepatitis B vaccines as soon as possible after exposure (preferably within 24 hours). The hepatitis B vaccine and HBIG can be administered simultaneously in different injection sites. When the patient (source) has an unknown status of infection with hepatitis B and the LPN has completed the hepatitis B vaccine series, no further treatment is required (CDC, 2020).

PEP, if required, is still recommended in LPNs who are pregnant and/or breastfeeding, as the hepatitis b vaccine is considered safe in pregnancy and will not harm the baby.

Currently, no recommendations exist for post-exposure prophylaxis for hepatitis C.

HIV Post-Exposure

Exposure to HIV can be frightening and should be handled according to the facility’s policies. In general, a needle stick wound should be washed with soap and running water. Irrigation with water or saline is necessary if a splash to the eyes, mouth, or skin occurs. Baseline testing can and should be performed to determine the LPN’s baseline HIV status. Further testing may occur at four weeks, 12 weeks, and six months post-exposure (Territo et al., 2022).

PEP should occur as soon as possible after exposure to HIV. If feasible, PEP should be administered within two hours of exposure as its effectiveness starts to decrease after two hours. PEP should be administered no later than 72 hours after exposure (Alghamdi et al., 2020). If the source is tested for HIV and comes back negative, PEP can be discontinued.

PEP for HIV exposure encompasses a 28-day course of a 3-drug regimen. The recommended regimen includes tenofovir DF 300 mg plus a fixed-dose combination of emtricitabine 200 mg once daily and raltegravir 400 mg twice daily or dolutegravir 50 mg once daily (CDC, 2021).

Legal Responsibilities

As we have discussed, there are many aspects of IV therapy, including the scope of practice and infection control. Another element of IV therapy involves legal responsibilities. Administering IV therapy to patients is one of the nurses' most legally significant tasks. Lawsuits can arise for a variety of reasons and include the following:

  • Wrong solution. A wrong solution or medication being administered to a patient not only can result in a lawsuit, but it also can result in the death of a patient.
  • Wrong dose. A wrong dose may be higher or lower than the ordered one, which may cause problems for the patient (Cavell and Mandaliya, 2021). A higher dose may cause an overdose, such as with pain medication. A lower dose may result in an infection spreading, as with not receiving a full amount of ordered antibiotics.
  • Wrong route. All orders should specifically state the route of the medication being given. Administration via a wrong route may cause adverse effects.
  • Errors in infusion pump use. An infusion pump should be set up with the correct flow rate and administration time. If set up incorrectly, too much medication can be given in a short amount of time (Kirkendall et al., 2020).
  • Inappropriate placement of the device. For example, an IV placed in an extremity with a local infection and burn would be considered inappropriate (Beecham and  Tackling, 2022).
  • Infiltration. Infiltration involves medication or fluid being delivered to tissue surrounding an IV. It can cause serious harm to the patient, such as infection and necrosis (Odom et al., 2018).
  • Dislodgment of IV equipment. If not careful, an LPN may accidentally dislodge an IV catheter by getting an extremity caught in the tubing or tripping on the tubing. Dislodgement of an IV may cause additional IV insertion procedures increasing the risk of infection (Munoz-Mozas, 2022).
  • Failure to monitor for adverse reactions. Failure to monitor a patient for any adverse reactions from IV insertion, medication administration, or even routine monitoring can result in severe consequences for the patient.

Always adhere to the seven "rights" of giving medications to prevent lawsuits. They are:

  1. Right drug. It goes without saying that ensuring you have the right medication is paramount for various reasons. Patients can have different medical allergies, adverse reactions, and unexpected symptoms that could lead to catastrophic results. Read the medication label, triple-check the patient’s charts, and ensure you are administering the correct medication for that patient.
  2. Right patient (using two identifiers). Making sure you have the right individual is vital in medication administration. The standard is to check with at least two other sources that you have the correct person before administering medication. The most experienced nurses can make a mistake if they are tired, overworked, or managing several patients at once. Despite your experience level, you should always verify that you are giving the right person the right medication (Smeulers et al., 2015).
  3. Right time. Many medications have a specific time to be administered, either due to the patient’s other medications or around their meals. Not all medications require a specific time, but it is your responsibility to know which ones do and at what time. Medication administration should be recorded so that anyone treating them knows when it was last administered.
  4. Right dosage. The right dose is also essential, as the wrong dose could lead to overdosing a patient and possibly harming them. The patient’s correct dose should be noted in their chart, and you should also know the form in which they should receive medication. Are they taking pills, receiving medications through IV, or swallowing liquids? These methods all require various doses.
  5. Right route. “Route” refers to where and how the medication is given to a patient. While most medications are taken orally, this is not always the case. The notes surrounding how medications should be administered are essential to keep communication clear as shifts change and other LPNs are due to administer medication. Medication can be given in several ways, including rectally, vaginally, through the skin, eyes, ears, lungs, etc. Errors may occur if the route is not correctly communicated.
  6. Right reason. Each time medication is given, the person administering it should ensure that it is being given for the right reason (e.g., Tylenol for teething pain, breathing treatment for asthma attack). Consulting the healthcare plan or inclusion support plans for the appropriate symptoms can help ensure that the medication is given for the right reasons.
  7. Right documentation. It is the sole responsibility of the person administering the medication to document that administration properly. Without proper documentation, communication can get lost between medical professionals. Always double-check your documentation and ensure all details are present and correct.

Some facilities will also include “right response” as the eighth right of medication administration. Last but certainly not least is the patient's response to the medication administered. Anytime a patient is given medication, their response should be recorded to ensure that it is known to anyone treating the patient. Additionally, the level to which the medication helps the patient should be recorded to track what medication is working and which is not (Hanson and Haddad, 2022).

Failure to adhere to these principles of medication delivery can result in fines, loss of license, and even jail time.


We live in a culture of measurement. Actions, observations, and intent are all subject to review and comparison toward desired standards. Records must be generated, stored, and maintained to meet pressures internal to our profession and those that exist externally. Medical documentation has become a component of health care as significant as rendering hands-on, direct-person interventions. Updating our documentation premise and process knowledge is essential to honing our professional and technical skills.

Medical documentation is written or electronically generated information about a patient describing the services or care provided. Depending on the facility, documentation may be in the form of paper records or electronic documents. Electronic documents include computer-created medical record files, faxes, e-mails, texts, pictures, and video or audio recordings. Through documentation, key observations, decisions, actions, and outcomes can be communicated and preserved in a lasting fashion. Documentation intends to create a lasting accurate accounting of what occurred and when (Kasaye et al., 2022).

The challenge today is to provide concise yet comprehensive records that accurately portray the patient's experience while meeting the standards of professional and organizational care, regulatory requirements, fiscal responsibility, and criteria for reimbursement. The care record is a legal document and includes information from nurses and other health professionals who have contributed to patient outcomes.

The health record should read like a novel with a beginning (admission), a middle (active treatment to better the patient), and an end (discharge or transfer). When the documentation records are unclear and do not directly define why care is being given and the result of the care, then there are definite issues affecting payment for care and organizational accreditation. Meeting the record of care elements of performance is a continuing challenge. It is important to know what is required and ensure those requirements are met. Unfortunately, forgetting or neglecting to date and time documentation entries is one of the top reasons health organizations fail standards.

Documentation in the patient chart provides a means by which health professionals can communicate information to each other. Notes on what each of us observes and how we respond with interventions or by forming care plans must be entered into the chart.

Documentation of IV therapy should include the following:

  • date and time of insertion
  • site and preparation of insertion
  • number of attempts to start IV
  • size and type of catheter inserted
  • medications and solutions administered/hung
  • total intake of IV fluids
  • date and time of IV removal
  • management of complications

Quality nursing documentation includes the following aspects:

  • It is written to reflect the objective clinical judgment of the nurse, what they hear, see, or have expressed to them directly from the patient. Data and conclusions are reported, not assumptions.
  • It must be patient-centered. The patient's perceptions as reported to the nurse, along with the nurse's response or interventions.
  • It contains the nurse's actual work, such as education, physical intervention, or psychosocial support.
  • It must be presented in a sequential, logical manner.
  • It must be time-sensitive, with the documentation starting immediately following an event or soon afterward.
  • It records variances in care.
  • Must satisfy legal requirements by providing a comprehensive description of the patient's experience, demonstrating that the nurse understands the patient's diagnosis and condition with interventions to manage any issues arising on their watch that can potentially affect the patient's outcome.

Major institutions have created documentation standards to help guide LPNs and other healthcare professionals. The American Nurses Association (ANA) has published the Scope and Standards of Practice and Principles for Nursing Documentation. The Scope and Standards of Practice describe services that LPNs and all other healthcare professionals can perform within their scope and under their license (ANA, 2021). The Principles for Nursing Documentation lists and describes essential steps in creating clear, accurate, and concise documentation (ANA, 2010).

Technical tips for documentation include:

  • Using the appropriate form.
  • Use only organization-approved abbreviations and acronyms.
  • Document symptoms utilizing the patient’s own words.
  • Do not backdate or write on previously written lines.
  • Sign your full name and title.
  • Review organizational policies on correcting documentation errors and late entries.
Documentation Do's
  • Be timely with chart notes.
  • Be accurate with information.
  • Be complete in what you write.
  • Be legible.
  • Be objective and provide facts.
  • Be clear about pertinent negative findings.
  • Be observant of reporting unusual interactions between patients and others.
  • Be correct in spelling, grammar, and use of approved abbreviations.
  • Be sure patient identifying information is on each page of the written chart.
Documentation Don'ts
  • Avoid criticism.
  • Avoid erasing or obliterating unwanted chart entries.
  • Avoid gaps in your written notes.
  • Avoid sarcasm, slurs, use of humor, and profanity.
  • Avoid concluding – give the facts instead.
  • Avoid removing parts of the chart to work on elsewhere.
  • Avoid asking others to document for you.
  • Avoid documenting for others.
  • Avoid mentioning incident reports within the patient chart.

Legally Defensible Charting

Specific guidelines apply regardless of the documentation format you use. The following tips will help ensure that your recordkeeping can be defended in the courtroom.

Legibility is essential. Never second-guess someone else's writing. Call the colleague for clarification, if necessary. Correct spelling and proper grammar are crucial for safe patient care because they enhance your professionalism. Ensure a dictionary is kept at the nurses' station and post a list of commonly misspelled words. Avoid abbreviations altogether when possible. If you must use them, use only abbreviations approved by your facility.

Make sure you have the CORRECT CHART for the CORRECT PATIENT before you begin writing. The medical record is a permanent legal "business record," and entries must not be made in pencil or erasable ink; write in permanent ink. Stick to blue and black ink. As a rule, courtroom proceedings will use copies of the record. Copying and electronic scanning machines duplicate blue and black ink with the highest clarity. If you use a highlighter in your record to note discontinued medication, ensure that your medical records department can effectively copy highlighted information — some copy machines "gray out" any writing covered by the highlighter.

If anything is secured into the medical record with tape (monitor strips, blood product labels, etc.), use double-sided tape or tape only onto blank paper. Even though the tape is clear and can be read through by the naked eye, a copy machine may "black out" the taped area. Faxes must be copied before inclusion in the chart. Unless you have a plain paper copy machine, the ink on the fax may be water-soluble and fade in a few days.

EVERY PAGE of the record must have the date and patient name; this is required for a record to be admitted in a courtroom. Your complete signature is required once per page. Your full signature is your name, followed by your professional designation. When adding a progress note, follow institutional policy to determine if you are to note the time that the entry is being added rather than the time that the observation took place.

Avoid block charting, such as "11:00 PM to 7:00 AM," as it gives the impression of vagueness. Note the exact times of all critical treatments, physician contact, or notices to supervisors. Any time you leave a message with someone in a physician's office, note the time and the name or title of the person taking the message.

Make sure the "proper" person does the documentation. For example, The Joint Commission (TJC) states that an RN should perform and document the initial assessment and care plan (TJC, 2016). Documentation by the proper person is essential in educational, nutritional, and rehabilitation assessments.

Avoid documentation practices that either allow or allude to the alteration or falsification of a medical record. Eliminate excess white space in your record. When making a progress note, write flush to the margin. Likewise, when you have completed your thought, draw a line through any remaining blank space on the line before signing your name. Do not leave blank lines between entries.

Do not make entries in advance. Wait until things happen before marking them down. Even the most predictable events can get off schedule in patient care.

To correct written entries, put a single line through the error, then add your initials and the correction date. You may note "error" or "mistaken entry." Do not use whiteout or tape designed to obliterate typographical errors. Do not correct another's error. Likewise, if you disagree with an entry, do not record your opinion next to the disputed entry. Discuss your conclusions with a supervisor to ensure that the patient receives the best care and that the chart reflects respect for all healthcare team members (American Health Information Management Association [AHIMA], 2014).

When possible, chart as soon as possible after you make an observation or provide care; this helps eliminate the chance of forgetting important data. Late entries, out-of-sequence entries, or addendum entries may sometimes be necessary. If the entry is made the following day, always cross-reference the entry so that the reader will read the additional note in the proper sequence. The following steps will eliminate misunderstanding:

  • Add the entry to the first available line.
  • Indicate clearly "late entry."
  • Record the day and time you are writing the entry.
  • In the body of the paragraph, indicate the day and time of the previous event now being described.

Never chart for someone else. Do not write anything if you did not participate in an activity or observe someone else's care. If you are on duty when a nurse calls to report that she forgot to record a patient interaction, chart it in the following way:

"At 8:35 AM, Nurse Joann Green called and reported that at 5:30 AM this morning, she observed…."

Understand countersigning. Only countersign notes when required by the institution.

  • If you merely review someone's note, co-sign in the following manner:
    • "Student nurse name/Entry reviewed by Jane Doe R.N."
  • If you actually participate in the activity, co-sign in the following manner:
    • "Student nurse name/Jane Doe R.N."

Keep documentation objective. Do not chart opinions or assumptions. Rather than "the patient was unresponsive," your notes should report what you saw through objective assessment. Document what you see, hear, or smell. Avoid phrases like "perhaps,” "maybe," or "I think."

Be careful to avoid labeling the patient. For example, avoid descriptive terms like "demanding,” "drug seeking,” "abusive,” "lazy,” "drunk,” "mean,” "litigious," or "out-of-control." Instead, note observations as a description of the behaviors.

Unusual occurrences and patient injuries need to be documented. Objectively record what you witness without making any conclusions or unsubstantiated assumptions. Use quotation marks when documenting comments from the patient, roommate, or visitors. Record the patient's vital signs, physical condition, mental condition, subjective complaints, physician's notification, arrival, and treatment details. However, do not mention in the patient's record that an incident report or occurrence report was filled out.

Always document a patient's uncooperative behavior. For example:

  • leaving against medical advice
  • refusing or abusing medications
  • failing to follow a diet or exercise plan
  • refusing to follow instructions to stay in bed or ask for assistance
  • failing to give information that affects care, such as complete history, current medication, or treatments
  • patient or family tampering with traction, IVs, or monitors
  • failing to follow up with visits to a clinic or physician
  • bringing unauthorized items into the facility

Document any safeguards or other preventive measures to protect your patient (e.g., night light left on, call light available, floor clear of trip hazards, etc.).

A chart should note that the facility's safekeeping for valuable possessions system was explained and made available to the patient. Encourage the patient or family members to send any possessions home. If they agree, have them sign their names next to a documented statement. Discuss the availability of a safe and ensure that all items put in the safe are recorded on a receipt complete with the patient's name and ID number. Describe each item in detail using objective language, for example, a “yellow ring with a clear stone” instead of charting a “gold diamond ring.” Update the list of valuables frequently for long-term patients. Before a patient is transferred, take an inventory of the list of valuables to verify the location of the items.

Document medication administration as thoroughly as possible. Note the date, time, initials, method of administration, and, if applicable, the site where the medication was given. Document the site of the infusion, the type and amount of fluid, any medications added, and the administration rate of IV infusions. At least once a shift, note the condition of the IV site and the type and size of the catheter (FAC, 2013).

If a medication is given for pain, note the site of the pain and its severity. Then follow up, noting the effectiveness of the drug. When omitting a medication, document the rationale. For example, "pain medication held pending stabilization of vital signs." If a medication order is being questioned, tactfully document your conversation with the physician. If someone is giving your patient medication while you are off the unit, ensure that person charts that they administered the drug.

Avoid verbal and telephone orders whenever possible because of the high risk of errors. However, since it is not always possible, the proper method for documentation of verbal or telephone orders includes the following:

  • Time and date of the phone call
  • Write the order verbatim, and then read the order back to the physician
  • Document T.O./R.B. (telephone order/read back) or V.O./R.B. (verbal order/read back) followed by the physician's name and your name

It is easy to fall into the trap of quick charting as tasks and responsibilities build up. However, care should be taken to avoid common charting errors (FAC, 2013). These common errors include: 

  • failing to record pertinent health or drug information
  • failing to record nursing actions
  • failing to record that medications have been given
  • recording in the wrong patient's medical record
  • failing to document a discontinued medication
  • failing to record drug reactions or changes in the patient's condition
  • transcribing orders improperly or transcribing improper orders
  • writing illegible or incomplete records

Common documentation errors often involve specific words considered risky and should be avoided. They include:

  • Accidentally
  • Apparently
  • Appears
  • Assume
  • Confusing
  • Could be
  • May be
  • Miscalculated
  • Somehow
  • Unintentionally



  • Only information collected through your senses should be documented.
  • Describe the behavior, do not label the patient.
  • State facts, not value judgments such as "no change” or “ate well."
  • Use neutral language.
  • Avoid documenting your own bias.
  • When you make an error, state precisely what you did or failed to do and that you notified the patient's provider and the provider's response (ANA, 2010).


  • Be precise and quantify whenever possible.
  • Be sure to make clear who gave the care.
  • Review the contents carefully, especially if countersigning with someone. Be sure to perform medication calculations if countersigning (ANA, 2010).


  • Document condition changes (even if there is none).
  • Document patient responses, even if unusual, undesired, or ineffective.
  • Document the communication/education that occurs with the patient and family.
  • Ensure there are entries in all spaces on all relevant assessment forms.
  • Use N/A or other designation per policy for items that do not apply to your patient.
  • Do not leave blanks. Blanks are hazardous as they allow for additional entries not made by you. Others may make entries in such blanks by mistake or to purposely falsify records. Be sure there are no blanks at the bottom of the previous page (ANA, 2010).


  • Date and time are critical in establishing a timely response, and they are necessary to be legally upheld in court. Electronic entries are automatically stamped with the date and time. If you refer to an earlier entry, be sure to note that.
  • Do not chart in advance, and do not leave documentation until the end of the shift. Advanced charting is considered record falsification and is illegal. It also contributes to confusion and may ultimately harm patients. It is easy to forget critical pieces when rushing to document.
  • It is easy to forget to document when managing several patients; ensure there is time to document between care when possible. Charting as the shift progresses will help keep your documentation more manageable and in a sequential manner.
  • Without thorough documentation, you must rely on your memory of events; this may not hold up in a court of law.
  • Colleagues providing temporary coverage or who take over care will rely on up-to-date information documented in the chart (ANA, 2010).

Legal Violations

There are certain precautions that LPNs must take to prevent mishaps from occurring, ones that could spell legal trouble. To name a few, LPNs must not work outside their scope of practice, must adhere to policies and protocols to prevent infections, and ensure their charting follows the above guidelines.

The state of Florida has outlined the steps and consequences of accidental and intentional errors.

64B9-8.001 The Probable Cause Panel

The state of Florida has enlisted the help of a probable cause board to determine a probable cause of an incident.

  • The determination as to whether probable cause exists shall be made by a majority vote of a probable cause panel of the board.
  • The board establishes three probable cause panels of two persons each to be appointed by the chairman of the board. Each panel may have one former board member serve, and at least one member of each panel must be an active licensee of the board. No more than one member of each panel shall be a consumer member. One member of each panel shall be the designated chairman. The board may select one panel to review the cases closed by the department.
  • If a case needs to be reconsidered by the probable cause panel for any reason, it must be taken to the panel that initially considered it.
  • The panel shall suggest penalties for inclusion in any stipulations between the department and the licensee based on the material submitted by the department, the board's past treatment of similar cases, and the board's disciplinary guidelines. All stipulations and terms shall be subject to the board's approval or rejection.
  • The panel may consider and recommend rules concerning disciplinary actions, procedures, and penalties to the full board (FAC, 2018).

64B9-8.003 Citations

There are specific reasons that LPNs may receive a citation, such as practicing out of scope.

  • "Citation" means an instrument that meets the requirements set forth and is served upon a licensee to assess a penalty.
  • The agency may issue a citation to the subject within six months after filing the complaint, which is the basis for the citation. All citations will require that the respondent correct the violation, if remediable, within a specified period and impose whatever obligations will remedy the offense.
  • The board designates the first instance of the following as a citation violation, which shall result in a penalty of $100.00:
    • False, deceptive, or misleading advertising provided no criminal prosecution resulted and no practice issue was involved.
    • Improper use of a nursing title provided no practice issue was involved or no criminal prosecution resulted.
    • Unprofessional conduct, using abusive, threatening, or foul language in front of a patient or directing such language toward a patient (FAC, 2019).

These are only a few examples pertinent to the LPN scope of practice. LPNs should abide by all rules set forth to ensure optimal patient outcomes.

64B9-8.0045 Minor Violations

The board deems the following violations to be minor:

  • False, deceptive, or misleading advertising provided no criminal prosecution resulted.
  • Improper use of a nursing title provided no practice issue was involved, or no criminal prosecution resulted (FAC, 1995).

These violations are listed as minor. However, they may have lasting effects on the career of an LPN.

64B9-8.005 Unprofessional Conduct

Unprofessional conduct shall include:

  • Inaccurate recording
  • Misappropriating drugs, supplies, or equipment
  • Leaving a nursing assignment without advising licensed nursing personnel
  • Violating the integrity of a medication administration system or an information technology system
  • Falsifying or altering patient records or nursing progress records, employment applications, or time records
  • Violating the confidentiality of information or knowledge concerning a patient
  • Discriminating based on race, creed, religion, sex, age, or national origin in the rendering of nursing services as it relates to human rights and dignity of the individuals
  • Impersonating another licensed practitioner or permitting another person to use their certificate to practice nursing
  • Practicing beyond the scope of the licensee's license, educational preparation, or nursing experience
  • Using abusive, threatening, or foul language in front of a patient or directing such language toward a patient
  • Delegating the performance of professional responsibilities to a person who the licensee knows, or has reason to know, is not qualified by training, experience, or authorization to perform them (FAC, 2021)

Unprofessional conduct can result in citations, fines, and loss of employment.

64B9-8.006 Disciplinary Guidelines; Range of Penalties; Aggravating and Mitigating Circumstances

The legislature created the board to protect the public from nurses who do not meet minimum requirements for safe practice or pose a danger to the public. The suspensions, restrictions of practice, and conditions of probation used by the board in discharging its duties shall include, but are not limited to, the following:

  • Suspension until an appearance before the board or for a definite period and demonstration of ability to practice safely.
  • Suspension until an appearance before the board, or for a definite period, and submission of mental or physical examinations from professionals specializing in the diagnosis or treatment of the suspected condition, completion of counseling, completion of continuing education, and ability to practice safely.
  • Suspension until fees and fines are paid or proof of continuing education completion is submitted.
  • Probation with the minimum conditions of not violating laws, rules, or orders related to the ability to practice nursing safely.
  • Probation with specified continuing education courses in addition to the minimum conditions. In those cases involving unprofessional conduct or substandard practice, including recordkeeping, the board finds continuing education directed to the practice deficiency to be the preferred punishment.
  • Personal appearances before the board to monitor compliance with the board's order (FAC, 2022). 

The board ensures that the LPN remedies any disciplinary action taken against them.

64B9-8.011 Reinstatement of Suspended Licenses

  • When the board has suspended a nurse's license,  the licensee, by petition, shall demonstrate compliance with all terms and conditions of the final order and the present ability to engage in the safe practice of nursing to obtain reinstatement.
  • To demonstrate the present ability to engage in the safe practice of nursing, the nurse must submit evidence which may include:
    • Completion of continuing education courses approved by the board, particularly if the disciplinary action resulted from unsafe practice or the nurse has been out of practice for many years.
    • Participation in nursing programs, including refresher courses, clinical skills courses, and any board-approved nursing education programs leading to licensure in this state, mainly if the nurse has been out of practice for several years.
    • Submission of evaluations of mental or physical examinations by appropriate professionals, which attest to the nurse's present ability to engage in safe practice or conditions under which safe practice can be attained.
    • Completion of treatment within a program designed to alleviate alcohol or other chemical dependencies, including necessary aftercare measures or a plan to continue such treatment as appropriate.
    • Other educational achievements, employment background, references, successful completion of criminal sanctions imposed by the courts, or other factors which would demonstrate rehabilitation and present ability to engage in the safe practice of nursing (FAC, 2016).

It is often easy to make mistakes when caring for a patient, whether through IV therapy or documentation. Care should be taken to ensure all requirements and standards are met.

Case Study

Joe is an IV-trained LPN who works at an outpatient infusion center. The RN left sick around noon. The doctor is preparing to leave at his usual time, 5 PM. Joe still has an hour left of chemo for one patient who is doing well. Joe does not say anything because he does not want his boss, the doctor, to be upset with him. He also does not want to remind the doctor that he cannot be by himself as an LPN. What if the doctor thinks about hiring an RN-only staff?

The law states that an LPN can only do chemotherapy under direct supervision. If Joe is the only staff on the premises, he is practicing outside his scope of practice. He might get away with it. On the other hand, if something happens to the patient, he could lose his license. Because Joe did not notify the doctor of the situation, Joe has taken on sole responsibility, which is malpractice. It is also not an ethical thing to do. Joe had an obligation to remind the doctor that the RN left early and the doctor had to be on the premises until the infusion was complete.


IV therapy is a common practice for LPNs. Skills and tasks we perform often can become mundane, and we may consider cutting corners to spare time. Cutting those corners can result in legal trouble, including citations, fines, and losing a license that was worked so hard for. LPNs should ensure that IV therapy is performed correctly and within the correct scope of practice. While IV therapy is being performed, infection control precautions and aseptic technique should be at the forefront of the mind, as IV insertion is an invasive process. IVs can expose a patient to unnecessary bacteria if improper technique is used. Should an incident that puts the patient and LPN at risk occur, proper precautions should be taken. If an LPN is exposed to potential diseases such as hepatitis B or HIV, post-exposure may include PEP, vaccines, and blood draws. Documentation of the incident and regular chart documentation, in general, should follow the guidelines for legally defensible charting and the dos of documentation. Failure to do so may result in further unintended consequences. Following your state’s NPA and guidance for IV therapy is pertinent for LPN and patient success.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.


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