Select date

Checklist completed


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

How full is bag?

Orange sticker

Date on Sticker

Initials on the sticker

Securement (Statlock)

Tamper Evident Seal (TES) Intact

No Dependent Loops

Tubbing and bag below bladder

Bag NOT touching the floor

Staff Signature
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.