General Information

Urinary Catheter Present on admission?

Date of Insertion?

Is there a Physician Order?

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

Today's Indication for Foley
Today's Indication for Foley
Maintenance Practices

Peri care completed once per shift (if possible ask patient)

Bag cover on if not in patient room?

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

Orange sticker on tubing present?

Initials on the sticker

Date on Sticker

Securement (Statlock) in place?

Tamper Evident Seal (TES) Intact?

No Dependent Loops

Tubing 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.