Intravesical Therapy Instillation Procedure Note

Date/Time: [Date and time of encounter]

Location: [Clinic/facility/unit]

Performing Clinician: [Name, credentials]

Ordering Clinician: [Name, credentials] (Include only if different from performing clinician.)

Indication: [Oncologic indication or clinical rationale]

Regimen/Protocol: [BCG induction/maintenance / Intravesical chemotherapy agent and protocol]

Treatment Number: [#X of Y]

Pre-Instillation Screening

(Do not default to negative findings; document only what was verified today. If a required item was not assessed, document "Not assessed" with reason and safety disposition.)

Vitals and Symptom Screen

• Temperature (measured): [Value and unit]
• Fever/chills: [Present / Absent / Not assessed]
• Dysuria/urgency beyond baseline: [Present / Absent / Not assessed]
• Gross hematuria: [Present / Absent / Not assessed]
• Suprapubic pain: [Present / Absent / Not assessed]
• Systemic symptoms (flu-like illness, cough, joint pain, rash): [Present / Absent / Not assessed]

Urine Evaluation

• Screening approach today: [Symptom-based only / UA-dip performed / UA with microscopy performed / Culture on file]
• UA/dip findings (if performed): [Summary or "Pending"]
• Urine culture status (if applicable): [No recent culture / Negative / Positive with organism / Pending]

Contraindications and Risk Factors – All Agents

• Suspected bladder perforation: [Yes / No / Not assessed]
• Active gross hematuria today: [Yes / No / Not assessed]
• Symptomatic UTI or high suspicion: [Yes / No / Not assessed]
• Recent instrumentation or difficult catheterization risk factors: [Yes / No / Not assessed]
• Pregnancy/lactation (if applicable): [Pregnant / Lactating / Negative / Not applicable]

Additional Screening – BCG Only (Include only if BCG is planned.)

• Days since TURBT/biopsy: [Number of days / Not applicable]
• Days since any traumatic catheterization: [Number of days / Not applicable]
• Immunosuppression status: [Active immunodeficiency / On immunosuppressants / Recent systemic chemotherapy / None]
• Current systemic antibiotics that may interfere: [Yes / No] (If yes, list agents.)

Immediate Post-TURBT Chemotherapy Considerations (Include only if immediate post-resection instillation is planned.)

• Perforation suspected: [Yes / No]
• Bleeding requiring irrigation: [Yes / No]

Go/No-Go Decision (Required. Select one statement and complete as indicated.)

• Screen completed; patient appropriate to proceed with intravesical [agent].
• Instillation deferred due to: [reason]; plan: [next steps]; ordering clinician notified.

Medication Verification

• Agent: [BCG strain / Mitomycin / Gemcitabine / Docetaxel / Other]
• Dose: [Dose and units]
• Total instillation volume: [mL]
• Diluent (if applicable): [Type and volume]
• Route: Intravesical
• Administration method: [Gravity / Syringe]
• Independent double-check performed: [Yes / No / Not required per protocol]

(Optional billing elements—include only if not captured elsewhere.)

• Lot number: [Value]
• Expiration date: [Date]
• Amount administered: [mL or mg]
• Amount discarded: [mL or mg / No wastage] (If discarded, state reason.)

Procedure

Consent: [Written consent on file / Verbal consent obtained today / Per institutional policy for routine instillation]

Catheterization

• Catheter type/size: [Type, material, Fr size]
• Lubricant/anesthetic used: [Agent and amount / None]
• Number of attempts: [1 / Number if more than one]
• Urine return confirmed: [Yes / No] (If no, document actions taken.)
• Volume drained prior to instillation: [mL / Not measured]
• Traumatic catheterization indicators: [None / Present] (If present, describe findings and impact on decision to proceed.)

Instillation

• Start time: [HH:MM]
• Total volume instilled: [mL]
• Catheter management: [Removed immediately / Clamped and left in place] (If left in place, state rationale.)

Dwell Time Plan

• Planned dwell duration: [Minutes]
• Planned void time: [Approximate time]
• Positioning instructions provided: [No special positioning required / Reposition periodically]

Immediate Post-Procedure Assessment

• Patient tolerance: [Well tolerated / Mild discomfort / Poorly tolerated]
• Immediate urinary symptoms after catheter removal: [None / Urgency / Dysuria / Spasm / Other]
• Urine appearance: [Clear / Pink-tinged / Gross blood]
• Vasovagal or other systemic symptoms: [None / Present] (If present, describe.)
• Complications: [None / Complication and actions taken] (Required even if none.)
• Spillage or staff exposure: [No / Yes] (If yes, document decontamination and incident reporting.)

Patient Instructions Documented

(Document education provided and patient understanding; do not include full instruction text.)

Core instructions (all agents): Voiding timing after dwell, hand hygiene and perineal cleansing, hydration after first void, expected common side effects, clinic contact information and after-hours escalation.

• Reviewed: [All items reviewed / Partial—specify items not reviewed]

BCG-specific counseling: (Include only if BCG used.) Urine disinfection method and duration, splash avoidance (sit to void), household contact precautions, sexual precautions during treatment course, urgent call thresholds (fever, persistent systemic symptoms, severe urinary symptoms).

• Reviewed: [All items reviewed / Partial—specify items not reviewed]

Intravesical chemotherapy–specific counseling: (Include only if chemotherapy used.) Splash avoidance, skin cleansing if contact occurs, protocol-specific optimization instructions if applicable.

• Reviewed: [All items reviewed / Partial—specify items not reviewed / Not applicable]

• Handout provided: [Yes—title / No]
• Patient understanding: [Verbalized understanding / Teach-back performed / Could not demonstrate understanding]
• Questions addressed: [Yes / No / None raised]

(If patient could not understand or declined instructions, document mitigation steps.)

Plan

• Next instillation: [Date scheduled / Scheduling pending]
• Pre-next treatment labs/UA: [None / UA-dip / UA with culture if indicated / Other]
• Symptom management medications ordered: [Agent, dose, frequency / None]
• Contingency instructions: [Summary of instructions if symptoms develop]

______________________________
[Performing clinician electronic signature, credentials]
[Date/time signed]