Urinary (Foley) Catheter Placement, Change, or Removal Procedure Note

Date/Time: [Procedure start date and time]

Location: [bedside / ED / ICU / clinic / OR / other]

Operator: [Name, credential]

Assistant: [Name, credential] (Include only if an assistant participated; otherwise omit this line.)

Procedure Performed: [Insertion / Exchange / Removal / Attempted—Unsuccessful]

Indication

[Clinical indication and supporting data] (For insertion: state the specific indication such as acute urinary retention, accurate I&O monitoring, perioperative need, or wound protection; include relevant objective data such as bladder scan volume; note alternatives considered or attempted if applicable. For exchange: specify the trigger such as obstruction, closed-system compromise, or malfunction. For removal: confirm the original indication has resolved and note whether removal is per nurse-driven protocol or provider order.)

Pre-Procedure

Consent: [Consent obtained from patient / surrogate / implied in emergency] (State that risks, benefits, and alternatives were discussed and agreement obtained. If implied consent or surrogate decision-making was used, state the rationale.)

Safety Pause: [Patient identity, procedure, and allergies verified] (Include if performed per institutional policy; omit this line if not required or not performed.)

Relevant History: [Pertinent risk factors] (Include only if present, such as urethral stricture, prior difficult catheterization, BPH, pelvic surgery/radiation, anticoagulation, or relevant allergies. Omit this line if none.)

Equipment

(Include this section only for Insertion or Exchange; omit entirely for Removal-only.)

Catheter: [Foley / Coude / 3-way / other], [size in Fr], [silicone / latex / other]

Balloon: [Volume inflated in mL]

Lubricant: [sterile lubricant / lidocaine gel]

Drainage System: [standard bag / leg bag]; [preconnected closed system: yes / no]

Securement: [stat-lock / tape / other]

Removed Catheter (exchange only): [Prior catheter type, size, material]; [removed intact: yes / no]; [catheter tip abnormalities if present]

Procedure Description

[Narrative description of the procedure performed] (Write a concise paragraph. For insertion: describe positioning, hand hygiene, sterile technique including gloves, drape, periurethral cleansing, and lubrication, catheter passage, confirmation of urine return before balloon inflation, balloon inflation, and connection to drainage; note number of attempts if more than one. For exchange: describe balloon deflation, removal with integrity confirmation and any catheter tip findings, then insertion steps for the replacement. For removal: describe balloon deflation, removal with integrity confirmation, and any notable meatal or skin findings. If difficulty was encountered, describe the nature of resistance, adjuncts used, and outcome. If contamination occurred, describe the deviation and corrective action taken. Do not state "sterile technique maintained" unless accurate. Do not state "atraumatic" if bleeding or trauma occurred.)

Findings

Urine Return: [yes / no]; [time to return if noted]

Initial Volume Drained: [mL] (Especially important for urinary retention.)

Urine Appearance: [Objective description such as clear yellow, cloudy, bloody, or sediment present] (Do not interpret appearance as evidence of infection.)

Specimen Collected: [none / UA / culture / other]; [collection method: sampling port / freshly placed catheter] (Include collection method if specimen obtained.)

Complications: [None / description of complications] (If present, describe: hematuria, urethral trauma, false passage concern, significant pain, vasovagal episode, balloon malfunction, failed placement, or other.)

Patient Tolerance: [tolerated well / required analgesia / procedure aborted due to pain / other]

Post-Procedure Status

[Catheter secured to prevent traction; drainage bag positioned below bladder level; tubing without kinks with dependent drainage confirmed] (Include securement method if applicable. Note any orders placed such as device order in EHR, intake and output monitoring, or irrigation/CBI.)

Patient Education

[Education provided to patient, family, or caregiver] (Topics include: hand hygiene before catheter manipulation, maintaining closed drainage system, keeping bag below bladder and off floor, routine hygiene without special meatal antiseptics, and when to seek help for fever, suprapubic or flank pain, worsening hematuria, absent urine output, or leakage. For discharge with catheter, include leg bag use, emptying technique, and follow-up plan. If education was not provided, state reason and plan to address.)

Plan

[Next steps based on procedure type] (Include only the applicable scenario below.)

• If ongoing catheterization: [Expected duration or removal criteria]; [daily reassessment responsibility]; [output monitoring plan]
• If removal with voiding trial: [Voiding trial protocol including timeframe to void, timing of bladder scan or PVR check, threshold for success, and contingency if trial fails]
• If discharge with catheter: [Follow-up appointment for removal or exchange]; [supplies provided]; [return precautions]
• If attempted but unsuccessful: [Escalation plan such as urology consult, imaging, or alternative urinary management]

(Omit any sections or lines that do not apply to the procedure performed. Do not assume consent was obtained, sterile technique was maintained, or complications were absent unless explicitly documented.)