MMH Urinary Catheter Inspectiion

• Visit Number

• Audit Date

  Date

General Information

• Date of Insertion?

  Date

• Indicate department where Foley was placed.

  Select Med/Surg SCA ESD OB OR HC OPC

  • Med/Surg
  • SCA
  • ESD
  • OB
  • OR
  • HC
  • OPC

• Is there a Physician Order?

  Yes

  No

  N/A

Today's Indication for Foley

• Urinary Retention or Bladder outlet obstruction

  Yes

  No

  N/A

• Accurate urine output measurements in the critically ill patient

  Yes

  No

  N/A

• Selected surgical procedures

  Yes

  No

  N/A

• Enter Procedure Type:

• Patient requires prolonged immobilization<br>

  Yes

  No

  N/A

• Assist in healing of open sacral wounds in the incontinent patient<br>

  Yes

  No

  N/A

• Improve comfort at end of life<br>

  Yes

  No

  N/A

• Catheter to discontinue order<br>

  Yes

  No

  N/A

Insertion Best Practices

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

  Yes

  No

  N/A

• Orange sticker on tubing nearest the bag?

  Yes

  No

  N/A

• Date on Sticker

  Date

• 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.)

  Less than 2 days

  Greater than or equal to 2 days

• Securement (Statlock) in place?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Seal is broken - Please Explain.

• No Dependent Loops

  Appropriate

  Inappropriate

• Tubbing and bag below bladder

  Yes

  No

  N/A

• Bag is above floor (not touching floor)?

  Yes

  No

  N/A

• Education Provided and Documented

  Yes

  No

  N/A

Reminders/Notes

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

• Notes:

Signatures

• Auditor Signature

  Sign