Select date
Date
Pt ID? Room #?
Sex?
Reason for catheter
Select
Known or suspected urinary tract obstruction
Neurogenic bladder dysfunction/Urinary retention
Urologic surgery, bladder injury, pelvic surgery
other surgical patients postop day 0-1
urinary incontinence w/ stage III or stage IV pressure ulcer
Need for accurate measurement of urinary output in ICU patient
Gross hematuria w/potential clots
Epidural catheter still in place
Palliativw care for terminally ill
Immmobility (complete bedrest)
Known or suspected urinary tract obstruction Neurogenic bladder dysfunction/Urinary retention Urologic surgery, bladder injury, pelvic surgery other surgical patients postop day 0-1 urinary incontinence w/ stage III or stage IV pressure ulcer Need for accurate measurement of urinary output in ICU patient Gross hematuria w/potential clots Epidural catheter still in place Palliativw care for terminally ill Immmobility (complete bedrest)
Catheter Type
Select
Bard Standard
Bard Urine Meter
Condom Cath
Temp Sensing
Other
Bard Standard Bard Urine Meter Condom Cath Temp Sensing Other
Red Tamper-evident Seal Present and intact?
Foley Catheter Secured to patient?
If yes, Type of securement?
StatLock
Tape
Strap
other
NO drainage tubing Looped or Kinked/ dependent loops observed?
Green Sheeting clip is being used- to sheet/gown?
Drain tube and bag below bladder?
Bag/Meter is not touching floor?
System labeled with insertion information?
Device Insertion Location
Select
ED
OR
ICU
MS
PCU
other
# Foley days?
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Jarrod Stahl
WOO- Foley Maintenance Assessment
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