Title Page
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Site conducted
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Conducted on
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Prepared by
Patient #1
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MRN
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Date of Admission
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Date of Insertion of Catheter/or Date placed
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Date of Culture
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Culture Result
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Is the bundle updated and completed per shift (no blanks)
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Baseline Culture done
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Catheter connected to urine drainage bag with unobstructed drainage bag with unobstructed flow at all times
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Catheter secured to patient by appropriate plaster
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Urine bag emptied regularly into separate clean container
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Collection bag kept below the level of bladder at all times
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Collection bag is not on the floor at any time
Patient # 2
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MRN
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Date of Admission
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Date of Insertion of Catheter/or Date placed
-
Date of Culture
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Culture Result
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Is the bundle updated and completed per shift (no blanks)
-
Baseline Culture done
-
Catheter connected to urine drainage bag with unobstructed drainage bag with unobstructed flow at all times
-
Catheter secured to patient by appropriate plaster
-
Urine bag emptied regularly into separate clean container
-
Collection bag kept below the level of bladder at all times
-
Collection bag is not on the floor at any time
Patient # 3
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MRN
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Date of Admission
-
Date of Insertion of Catheter/or Date placed
-
Date of Culture
-
Culture Result
-
Is the bundle updated and completed per shift (no blanks)
-
Baseline Culture done
-
Catheter connected to urine drainage bag with unobstructed drainage bag with unobstructed flow at all times
-
Catheter secured to patient by appropriate plaster
-
Urine bag emptied regularly into separate clean container
-
Collection bag kept below the level of bladder at all times
-
Collection bag is not on the floor at any time
Patient # 4
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MRN
-
Date of Admission
-
Date of Insertion of Catheter/or Date placed
-
Date of Culture
-
Culture Result
-
Is the bundle updated and completed per shift (no blanks)
-
Baseline Culture done
-
Catheter connected to urine drainage bag with unobstructed drainage bag with unobstructed flow at all times
-
Catheter secured to patient by appropriate plaster
-
Urine bag emptied regularly into separate clean container
-
Collection bag kept below the level of bladder at all times
-
Collection bag is not on the floor at any time
Patient # 5
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MRN
-
Date of Admission
-
Date of Insertion of Catheter/or Date placed
-
Date of Culture
-
Culture Result
-
Is the bundle updated and completed per shift (no blanks)
-
Baseline Culture done
-
Catheter connected to urine drainage bag with unobstructed drainage bag with unobstructed flow at all times
-
Catheter secured to patient by appropriate plaster
-
Urine bag emptied regularly into separate clean container
-
Collection bag kept below the level of bladder at all times
-
Collection bag is not on the floor at any time
Patient # 6
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MRN
-
Date of Admission
-
Date of Insertion of Catheter/or Date placed
-
Date of Culture
-
Culture Result
-
Is the bundle updated and completed per shift (no blanks)
-
Baseline Culture done
-
Catheter connected to urine drainage bag with unobstructed drainage bag with unobstructed flow at all times
-
Catheter secured to patient by appropriate plaster
-
Urine bag emptied regularly into separate clean container
-
Collection bag kept below the level of bladder at all times
-
Collection bag is not on the floor at any time
Patient # 7
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MRN
-
Date of Admission
-
Date of Insertion of Catheter/or Date placed
-
Date of Culture
-
Culture Result
-
Is the bundle updated and completed per shift (no blanks)
-
Baseline Culture done
-
Catheter connected to urine drainage bag with unobstructed drainage bag with unobstructed flow at all times
-
Catheter secured to patient by appropriate plaster
-
Urine bag emptied regularly into separate clean container
-
Collection bag kept below the level of bladder at all times
-
Collection bag is not on the floor at any time
Patient # 8
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MRN
-
Date of Admission
-
Date of Insertion of Catheter/or Date placed
-
Date of Culture
-
Culture Result
-
Is the bundle updated and completed per shift (no blanks)
-
Baseline Culture done
-
Catheter connected to urine drainage bag with unobstructed drainage bag with unobstructed flow at all times
-
Catheter secured to patient by appropriate plaster
-
Urine bag emptied regularly into separate clean container
-
Collection bag kept below the level of bladder at all times
-
Collection bag is not on the floor at any time
