Trial of Void/PVR Assessment Procedure Note

Date and Time: [Start time and end time or time range] (Include local date; use precise timestamps)

Location: [Location]

Author: [Name, credentials, role]

Ordering Clinician: [Name, credentials] (if different from author; otherwise state "Same as author")

Procedure Type: [passive trial of void / active-backfill trial of void / PVR measurement only] | Re-catheterization performed: [yes / no]

Indication

• [Reason for assessment: evaluate readiness for catheter removal / suspected urinary retention / post-operative voiding assessment / follow-up of prior elevated PVR / other]
• [Current catheter status: catheter type, size, days in place, original indication] (If unknown, document "Unknown")
• [Pertinent factors affecting voiding: recent surgery, neuraxial anesthesia, mobility, constipation, relevant medications] (Include only if applicable)

Procedure

(Document in chronological order with timestamps. Complete only the subsection(s) matching the Procedure Type. For numeric fields: use "Not measured" if measurement was not performed; use "Unknown" with explanation if measurement occurred but value unavailable. Never infer or estimate volumes.)

Consent: [verbal / written / not obtained] (If not obtained, document reason and who authorized) | Aseptic technique: [yes / no / not applicable]

Passive (Spontaneous) Trial of Void

(Complete only if passive trial performed)

Catheter removal: [Timestamp] | [Catheter type and size removed] | Tolerance: [well tolerated / discomfort / pain]

Hydration plan: [Oral / IV / not performed] [Type and amount if given]

• Void attempt 1: [Timestamp] | Voided volume: [mL] | Symptoms: [none / dysuria / suprapubic pain / urgency / straining / incomplete emptying sensation / other]

  PVR after attempt 1: [Measured: yes / no] (If yes:)

  • Method: [bladder scanner / straight catheterization] | Result: [mL] | Time since void: [minutes / Unknown]
  • (If bladder scanner: Scans: [#], Value used: [average / highest]. If catheterization: Catheter size: [Fr])

• Void attempt 2: [Timestamp] | Voided volume: [mL] | Symptoms: [as above]

  PVR after attempt 2: [Measured: yes / no] (If yes, include method, result, and details as above)

• (Add additional void attempts as needed, each with timestamp and measurements)

Active/Backfill Trial of Void

(Complete only if active/backfill trial performed)

Instillation: [Timestamp start–end] | Fluid: [sterile normal saline / other] | Total instilled: [mL] | Leakage during fill: [none / small / moderate / large] | Reason for stopping: [target reached / discomfort / leakage / other] | Tolerance: [well tolerated / discomfort / pain]

Catheter removal: [Timestamp] | [Catheter type and size removed]

First void: [Timestamp] | Time to first void: [minutes from removal] | Voided volume: [mL] | Symptoms: [none / dysuria / suprapubic pain / urgency / straining / incomplete emptying sensation / other]

PVR after void: [Measured: yes / no] (If yes:)

• Method: [bladder scanner / straight catheterization] | Result: [mL] | Time since void: [minutes / Unknown]
• (If bladder scanner: Scans: [#], Value used: [average / highest]. If catheterization: Catheter size: [Fr])

(If additional void attempts occurred, document each with timestamp, voided volume, symptoms, and PVR details if obtained)

PVR Measurement Only

(Complete only if PVR-only assessment performed)

• Measurement 1: [Timestamp] | Time since last void: [minutes / Unknown] | Method: [bladder scanner / straight catheterization] | PVR result: [mL]

  (If bladder scanner: Scans: [#], Value used: [average / highest]. If catheterization: Catheter size: [Fr], Volume drained: [mL], Urine appearance: [clear / cloudy / bloody / sediment / other])

• (Add additional measurements as needed, each with timestamp and details)

Procedure status: [Completed as planned / Aborted] (If aborted: [patient refusal / severe pain / hemodynamic instability / other])

Results

• Voided volume(s): [List each void with timestamp and measured mL; "Not measured" if not obtained]
• PVR value(s): [List each with timestamp and method; "Not measured" if not obtained]
• Symptoms: [none / dysuria / suprapubic pain / urgency / incomplete emptying sensation / unable to void / other]

Criteria used: [State explicit pass/fail criteria applied, including numeric cutoffs and timing thresholds] (Do not assume universal cutoffs; document actual criteria used for this patient)

Outcome: [PASS / FAIL / INDETERMINATE] — [Brief rationale referencing criteria and specific measurements] (Use INDETERMINATE when essential measurements not obtained; specify what is missing)

Disposition

Re-catheterization: [yes / no]

(If yes:)

• Catheter: [Foley / straight catheter] | Size: [Fr] | Balloon volume: [mL] (if Foley)
• Immediate return volume: [mL] | Urine appearance: [clear / yellow / amber / cloudy / bloody / clots / other]
• Tolerance/complications: [well tolerated / difficult insertion / trauma / bleeding / pain]

(If no: confirm patient education on monitoring and return precautions provided)

Complications: [none / hematuria / urethral trauma / vasovagal episode / pain requiring intervention / other]

Specimens: [none / urinalysis / urine culture] (If obtained: Source: [clean catch / straight catheter / Foley] | Rationale: [reason])

Follow-up Plan

• Next steps: [Timing of repeat void trial / further PVR assessments / discharge plan]
• Follow-up: [urology / primary care / other] [Timing]
• Return precautions reviewed: [unable to void within specified timeframe / worsening suprapubic pain or distension / fever or chills / gross hematuria or clots / severe dysuria]
• Medication changes: [none / alpha-blocker initiation / anticholinergic discontinuation / other] (Specify agent, dose, timing if applicable)
• Orders placed: [none / bladder scans / intake and output monitoring / other]