General Information
Date of Insertion?
Indicate department where Foley was placed.

Is there a Physician Order?

Today's Indication for Foley

Urinary Retention or Bladder outlet obstruction

Accurate urine output measurements in the critically ill patient

Selected surgical procedures

Enter Procedure Type:

Patient requires prolonged immobilization

Assist in healing of open sacral wounds in the incontinent patient

Improve comfort at end of life

Catheter to discontinue order

Insertion Best Practices

Is the Foley bag equal or less than half full? (If greater than half full - please Empty)

Orange sticker on tubing nearest the bag?

Date on Sticker

Initials on the sticker

SCIP - Has this catheter been in place 2 days or longer? (If 2 days please request documentation to continue from physician.)

Securement (Statlock) in place?

Tamper Evident Seal (TES) Intact -if not please explain in text below.

Seal is broken - Please Explain.

No Dependent Loops

Tubbing and bag below bladder

Bag is above floor (not touching floor)?

Education Provided and Documented


Clean port with alcohol when emptying the bag or accessing port for any reason.


Auditor Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.