Urinalysis/Urine Culture Collection Note (Pediatrics)

Date/Time: [Date and time of documentation]

Author/Role: [Clinician name and role]

Setting: [ED / clinic / urgent care / inpatient]

Indication / Clinical Question

(Format as one brief paragraph or 3–5 bullets. If indication is unclear, explicitly state: "Indication not documented at time of collection.")

• [Chief concern in patient/caregiver words]
• [Trigger for urine testing: fever without source / dysuria / frequency / abdominal pain / vomiting / new incontinence / foul-smelling urine / other]
• [Symptom duration and fever curve]
• [Key associated findings: hydration status, respiratory or GI symptoms]
• [Age context: infant under 3 months / toddler / toilet-trained child]

Risk Factors

(Use Yes/No/Unknown for each item. Use "Unknown" rather than leaving blank for items that materially affect interpretation. If risk assessment not required, replace checklist with: "Risk modifiers not assessed—not required for today's decision-making.")

• Prior UTI history: [Yes / No / Unknown]; [Number and recency if yes]
• Known GU anomalies/hydronephrosis/VUR: [Yes / No / Unknown]
• Recent antibiotics (past 7–14 days): [Yes / No / Unknown]; [Agent and last dose timing if yes]
• Immunocompromise or relevant chronic conditions: [Yes / No / Unknown]; [Details if yes]
• Constipation or bowel–bladder dysfunction: [Yes / No / Unknown / Not applicable] (toilet-trained children)
• Circumcision status: [Circumcised / Uncircumcised / Unknown / Not applicable] (young boys when relevant)

Urine Collection

Toilet-training status: [toilet-trained / not toilet-trained / uncertain]

Collection method: [clean-catch midstream / catheterization / suprapubic aspiration / bag or collection pad / indwelling catheter port]

Rationale for method: [Brief rationale: age, contamination risk, urgency, parent preference or refusal]

(Complete only the section corresponding to the collection method used.)

• If clean-catch:
  • Midstream obtained: [Yes / No / Unknown]
  • Perineal cleansing performed: [Yes / No / Unknown]
  • Technique instruction provided: [Yes / No]
• If catheterization:
  • Number of attempts: [Number]
  • Aseptic technique used: [Yes / No]
  • Comfort measures: [Topical anesthetic / sucrose / swaddle / distraction / other / none]
  • Complications: [None / blood-tinged urine / trauma / unable to pass / other]
• If bag/collection pad:
  • Specimen intended for: [UA only / UA and culture]
  • [Plan for sterile specimen if UA positive and culture needed] (Include only if applicable.)

(If non-sterile method used when culture reliability matters, explicitly document reason: parental refusal, anatomic barriers, failed catheterization attempts, other. Do not leave unstated.)

Specimen Handling

Collection time: [Time / "Collection time not recorded"]

Transport: [Sent to lab immediately / refrigerated / preservative tube used / POC only]

Delay: [None / reason and estimated duration] (Include only if delay occurred.)

Gross appearance: [Clear / cloudy / bloody / other] (Include only if abnormal.)

Urinalysis Results

UA performed: [Yes / No]

Status: [final / preliminary / pending / not obtained]

Reason not obtained: [Reason] (Include only if UA not performed or if culture sent without UA.)

Dipstick

• Leukocyte esterase: [negative / trace / 1+ / 2+ / 3+]
• Nitrite: [positive / negative]
• Blood: [negative / trace / 1+ / 2+ / 3+]
• Protein: [negative / trace / 1+ / 2+ / 3+]
• Specific gravity: [Value]
• pH: [Value]

Microscopy

(Include only if performed. Do not infer pyuria if microscopy not obtained.)

• WBC: [Value and units]
• RBC: [Value and units]
• Bacteria: [none / rare / moderate / many]
• Squamous epithelial cells: [none / rare / moderate / many] (contamination indicator)
• Casts: [Type and quantity] (Include only if present and clinically relevant.)

Interpretation: [Brief one-sentence interpretation if it affects management] (Do not state "UTI confirmed" based on UA alone.)

Urine Culture

Culture sent: [Yes / No]

Specimen method: [Collection method—must match above]

Time sent: [Time / Unknown]

Additional tests ordered: [STI NAAT / other] (Include only if applicable.)

Rationale if no culture sent: [One-line explanation] (Include only if culture not sent.)

Assessment

Working impression: [Suspected lower UTI (cystitis) / Suspected febrile UTI or pyelonephritis / UTI unlikely—alternate diagnosis suspected / Indeterminate pending culture] (Use "presumptive UTI" when UA and symptoms support but culture is pending. Do not claim confirmed organism, susceptibilities, or sterile specimen if method was bag or unknown.)

• [Key supporting or refuting feature]
• [Key supporting or refuting feature]
• [Differential consideration] (Include only if it changes workup or counseling.)

Plan

Antibiotics

(Include only if antibiotics are started or explicitly deferred.)

Status: [Started / Deferred]

• If started:
  • Drug: [Medication name]
  • Indication: [presumptive cystitis / presumptive pyelonephritis]
  • Dose: [mg/kg] weight-based; [mg] calculated
  • Route/Frequency: [PO / IV]; [Interval]
  • Duration: [Days]
  • First dose given: [Yes / No]; [Time if yes]
  • Allergies reviewed: [Yes / No]
  • Rationale: [Brief justification for empiric treatment]
• If deferred:
  • Reason: [UA negative / low clinical suspicion / awaiting culture / other]
  • Trigger to start: [Clinical or lab trigger that would prompt initiation]

Additional Workup

(Include only if applicable. If encounter is collection-only with no additional workup, state: "No additional workup indicated.")

• [Bloodwork ordered and indication]
• [Imaging ordered and indication]
• [Escalation of care if applicable]

Follow-up / Result Tracking

(Required whenever culture is pending or UA results will return later. Never omit responsibility assignment.)

Responsible clinician/team: [Name and role / ordering provider pool]

Review window: [Timeframe, e.g., within 24–72 hours]

Family notification plan: [Phone / portal]; [Voicemail permission: Yes / No]

Actions by Result

• Culture negative: [Plan: stop empiric antibiotics if appropriate, family counseling]
• Culture positive and susceptible: [Plan: continue or narrow antibiotic, total duration]
• Culture positive and resistant: [Plan: change agent, counseling, updated regimen]
• Contaminated/mixed flora: [Plan: repeat sterile specimen]
• No growth but persistent symptoms: [Plan: reassess or alternative diagnosis workup]

Return Precautions

• Worsening fever
• Vomiting or signs of dehydration
• Lethargy or decreased responsiveness
• Flank pain
• Inability to tolerate oral medications
• Decreased urine output

Counseling

(Include as applicable, 3–5 bullets maximum.)

• [Collection instructions if home specimen needed]
• [Explanation of why sterile method was recommended] (Include if applicable.)
• [Medication adherence and potential side effects]
• [When to seek urgent care or return earlier]
• [Consent documented for catheterization or suprapubic aspiration; parent present: Yes / No] (Include if invasive procedure performed.)

Culture Result Follow-up (Addendum)

(Complete when culture results finalize. Keep brief and audit-friendly; do not restate the initial evaluation.)

Date/time reviewed: [Date and time]

Final culture result: [Organism(s) and quantitative growth as reported]

Interpretation: [Infection / contamination / indeterminate]—[Brief rationale tied to collection method and clinical picture]

Relevant susceptibilities: [Only those affecting therapy decisions]

Clinical decision: [Continue / stop / narrow / broaden / change agent]; Updated diagnosis: [Confirmed UTI / UTI ruled out / Other]

Family notification: [Date, time, method, person contacted, key instructions given] (If unable to reach, document attempts and next steps.)

Follow-up visit: [Scheduled with timing / not required] (Include only if indicated.)