PICC Line Placement
Does
Entrustable Professional Activity (EPA) Checklist: Residents must document 3 successful PICC Line Placements prior
to performing with indirect supervision (with direct supervision immediately available).
Shows How
Knows How
RESIDENT: ___________________________________________
EXPECTATION:
KNOWS
KNOWS HOW
SHOWS HOW
Level: R1 R2 R3 R4
ASSISTS
DOES
Knows
Miller’s Pyramid
Medical Knowledge
1. The resident knows (can discuss) PICC Lines and their indications/contraindications; knows how to perform a PICC Line Placement; and
shows how to perform a PICC Line Placement?
Yes
No
N/A
Interpersonal & Communication Skills
2. The resident introduces her-/himself to the patient, explains the procedure adequately, answers all patient and family’s questions and
obtains informed consent?
Yes
No
N/A
Patient Care & Procedural Skill
3. The resident checks pertinent history, exams, and indications? The resident examines the patient prior to prep for appropriate site?
Yes
No
N/A
4. The resident performs (does) the procedure in a technically competent manner?
Scrubbed?
Ultrasound/Fluoro guidance?
Suture catheter in place?
Time out?
Seldinger technique?
Confirm dressing placement?
Sterile technique?
Catheter tip position?
Enter post-op orders, including “PICC line is OK for use”?
Yes
No
N/A
Medical Knowledge (& Communication Skills)
5. The resident creates an appropriate dictation which includes significant findings and pertinent negatives?
Yes
No
N/A
Practiced based learning and improvement
6. The resident selects appropriate additional views or maneuvers to accomplish proper PICC line placement?
Yes
No
N/A
Systems Based Practice
7. The resident uses principles of ALARA to minimize radiation dose?
Yes
No
N/A
Professionalism
8. The resident effectively communicates with patient, technologists and all others present before, during and after the procedure?
Yes
No
N/A
The Resident performed the procedure/examination at the following level (circle one):
KNOWS
KNOWS HOW
SHOWS HOW
ASSISTS
DOES
The resident performed this procedure in a competent manner?
Yes
No
(If No is selected, faculty must provide written formative feedback in the box below.)
PROVIDE FEEDBACK IN THE BOX BELOW:
The Resident has successfully completed 3 PICC Line Placements using US and Fluoroscopic Guidance and is competent to perform this procedure
with indirect supervision (with direct supervision immediately available).
Yes
No
N/A
Faculty Signature: ___________________________________________
Faculty Name/Title: __________________________________________
Date________________