Urinary Catheter Care/Change Procedure Note

Date/Time: [Procedure date and time]

Location: [ED / ICU / inpatient unit / clinic / home visit / other: [specify]]

Author: [Name, credentials]

Procedure Type: [Catheter care only / Catheter removal / Catheter insertion / Catheter exchange / Bag or valve change / Irrigation or flush]

Order Source: [Provider order / Standing protocol / Nurse-driven removal protocol / Perioperative order set / Other: [specify]]

Indication and Medical Necessity

Indication: [Brief statement of clinical reason for catheter presence or procedure today] (Do not infer; use charted indication if available.)

• [Select all that apply: acute urinary retention or obstruction / critical hourly urine output monitoring / perioperative need / wound protection / prolonged immobilization / comfort or end-of-life care / other: [specify]]
• Alternatives considered or attempted: [Timed toileting / external urinary collection device / intermittent catheterization / increased toileting assistance / not applicable]
• Planned duration or removal criteria: [Remove on [date or postoperative day] / trial of void planned [timing] / daily reassessment / remove when [criteria]]
• (If indication not documented in chart, state: "Indication not available in chart at time of encounter; will clarify with primary team.")

Pre-Procedure Assessment

• Patient identification: [Verified per policy: name/DOB/ID band/photo/other]
• Consent: [Verbal consent obtained / verbal assent / surrogate authorization / patient refused] (Include decision-maker if applicable.)
• Contraindication screening: [Known or suspected urethral injury / recent urologic surgery / artificial urinary sphincter present / latex allergy / prep agent allergy / none identified] (Document actions taken if any positive.)
• Pain/anxiolysis plan: [No premedication / topical anesthetic: [agent] / systemic analgesic or anxiolytic: [agent and dose] / other: [specify]]
• Baseline assessment: (For insertion or exchange) [Perineal/periurethral skin integrity]; [Patient-reported symptoms: pain/spasms/leakage/other]; [Bladder scan result: [mL] at [time], if retention or low output is a concern]

Catheter Information

• Existing catheter: (For removal or exchange) [Type: urethral Foley / suprapubic]; [Lumens: 2-way / 3-way]; [Size: [French]]; [Material: silicone / latex / antimicrobial-coated / unknown]; [Balloon volume: [mL] / unknown]; [Insertion date: [date] / unknown]
• New catheter: (For insertion or exchange) [Type: urethral Foley / suprapubic]; [Tip: standard / coudé]; [Lumens: 2-way / 3-way]; [Size: [French]]; [Balloon inflation: [mL] sterile water]; [Drainage system: bedside bag / leg bag / catheter valve]; [Closed system: yes]

(If catheter details are unavailable, document as "unknown" rather than inferring.)

Procedure Details

(Provide a concise, time-ordered narrative. Include only elements relevant to the selected procedure type.)

• Catheter care only: [Perineal/meatal hygiene performed]; [Securement assessed/adjusted]; [Tubing repositioned, no dependent loops]; [Bag emptied or changed]; [System integrity verified: no kinks, bag below bladder, closed system maintained]; [Patient tolerance]
• Catheter removal: [Reason for removal]; [Balloon deflated, volume withdrawn: [mL]]; [Catheter tip intact on inspection]; [Post-removal plan: voiding trial instructions, bladder scan timing and thresholds]
• Catheter insertion or exchange:
  • (If exchange) [Old catheter removed: balloon deflated [mL], catheter removed intact]
  • [Number of attempts]; [Ease of passage / difficulty encountered / resistance: none / at [location]]
  • [Placement confirmed by: urine return / appropriate insertion depth / balloon inflated without pain or resistance]
  • [Balloon inflated with [mL] sterile water]; [Connected to closed drainage system]; [Securement applied at [location]]; [Tubing positioned without dependent loops]
  • [Initial urine output: [mL]] (If measurable)
  • (If unsuccessful: Attempt stopped due to [resistance / pain / bleeding / other]; next steps: [urology consult / coudé catheter / bladder scan / imaging]; patient status: [stable / comfort measures provided].)
• Bag or valve change: [Bag/valve changed]; [Closed system maintained with minimal disconnection time]; [Securement confirmed]; [Dependent drainage verified]
• Irrigation or flush: (If ordered) [Closed-system technique via irrigation port]; [Solution: [type]]; [Volume instilled: [mL]]; [Return: clear / debris / clots]; [Patient response]; [Indication: obstruction / hematuria management / other]

Infection prevention technique: [Hand hygiene performed]; [Sterile/aseptic technique with sterile supplies]; [Closed drainage system maintained]; [Catheter secured to prevent traction]; [Dependent drainage ensured]. (For care-only encounters: Standard precautions used; closed system maintained.)

Findings

• Urine characteristics: [Volume: [mL]]; [Color]; [Clarity]; [Odor: none noted / [description]]; [Sediment/debris: none / present]; [Hematuria: none / [description]] (If not observed, state: "Urine characteristics not observed at time of encounter.")
• Specimen: [Obtained / not obtained] (If obtained: [Collection method: sampling port / from new catheter immediately after insertion]; [Port disinfected: yes]; [Tests ordered]; [Transport: routine / time-sensitive]) (Do not collect from drainage bag unless specifically ordered.)
• Site assessment: [Meatus/perineum: normal / erythema / excoriation / discharge]; [Securement site skin: intact / redness / breakdown]; [Suprapubic stoma: [appearance, drainage, dressing status]] (If applicable)

Patient Tolerance and Complications

• Tolerance: [Pain level: [scale or description]]; [Spasms: present / absent]; [Anxiety: present / absent]; [Overall tolerance: well / fair / poor]
• Complications: [None / bleeding / trauma / concern for false passage / balloon malfunction / catheter dislodgement / break in closed system / leakage / other: [specify]]
• Troubleshooting: (If applicable) [Kinks straightened / bag repositioned / dependent drainage verified / bladder scan: [result] / catheter replaced due to [obstruction / leakage] / irrigation performed: [solution, volume, response]]

Education Provided

• Topics covered: [Hand hygiene / keep bag below bladder and off floor / avoid kinks and disconnections / routine meatal hygiene without antiseptics / proper bag emptying / hydration / when to seek help]
• Verification method: [Verbal teach-back / return demonstration / written instructions reviewed]; [Caregiver present and included: yes / no / not applicable]
• (If education not provided: [Previously educated / acute situation / patient declined / deferred to [timing or person]])

Plan and Follow-up

• Indication review: [Continued indication confirmed]; [Daily reassessment plan]; [Removal criteria: [specify]]
• Monitoring: [Urine output goal: [mL/hr or mL/shift]]; [Bladder scan threshold: [mL]]; [Site care schedule]
• Orders: [Labs/cultures ordered]; [Specimen transport]; [Supplies needed: [bags / securement / other]]
• Follow-up: [Next visit or reassessment: [timing]]; [Responsible clinician]
• Escalation criteria reviewed with patient: [No urine output despite troubleshooting / fever or chills / new flank or suprapubic pain / catheter dislodgement / gross hematuria or clots / persistent leakage / blood at meatus]
• (If escalation criteria present during encounter: [Provider notified: [name, time, response]])

(Include only sections applicable to the encounter type. Omit sections that would be entirely empty. Do not infer or fabricate missing information.)