MMH Urinary Catheter Inspectiion - duplicate - duplicate

• Catheter Inpsection

• Visit Number

• Room Number

• Conducted on

  Date

• Select date

  Date

Checklist

• Checklist completed

  Yes

  No

  N/A

• Department

  Select Med/Surg SCA ESD OB OR HC OPC

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

Indications

• 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

• How full is bag?

  Appropriate

  Inappropriate

• Orange sticker

  Compliant - On tubing near Bag

  Non- Compliant

• Date on Sticker

  Date

• Initials on the sticker

• Securement (Statlock)

  Appropriate

  Inappropriate

• Tamper Evident Seal (TES) Intact

  Yes

  No

  N/A

• No Dependent Loops

  Compliant - On tubing near Bag

  Non- Compliant

• Tubbing and bag below bladder

  Yes

  No

  N/A

• Bag NOT touching the floor

  Compliant - On tubing near Bag

  Non- Compliant

Signatures

• Staff Signature

  Sign

• Auditor Signature

  Sign