Which items should be recorded when documenting IV rate changes or discontinuation?

• A. Only record the new rate and time of discontinuation.
• B. Record the new rate or time of discontinuation, site assessment, patient tolerance, and the identity of the nurse performing the procedure.
• C. Document only the site assessment and patient tolerance.
• D. Note the medication dosage changes for the next shift.

Answer: (B)

Recording IV rate changes or discontinuation requires capturing what changed, when it changed, and how the patient and site responded, so the care team has a complete picture for ongoing safety and accountability. The best documentation includes the new infusion rate and the exact time of the change or discontinuation, so future nurses know the current status and timing aligns with orders. It also notes the IV site assessment, looking for signs of infiltration, phlebitis, pain, swelling, redness, or infusion flow problems, because the site condition can influence decisions about continuing or modifying therapy. Documenting patient tolerance is essential to reflect how the patient is handling the change—any discomfort, adverse symptoms, or intolerance that might require slowing, stopping, or evaluating alternatives. Recording the identity of the nurse performing the procedure ensures accountability and traceability in the care record, which is important for handoffs, quality review, and safeguarding patient safety. Together these elements provide a complete, actionable record; the other options omit one or more critical pieces, such as the rate and timing, or site and tolerance, or accountability.