Title Page
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Document No.
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Prepared by
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Select date
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Pt ID? Room #?
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Sex?
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Reason for catheter
- 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)
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Catheter Type
- Bard Standard
- Bard Urine Meter
- Condom Cath
- Temp Sensing
- Other
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Red Tamper-evident Seal Present and intact?
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Foley Catheter Secured to patient?
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If yes, Type of securement?
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NO drainage tubing Looped or Kinked/ dependent loops observed?
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Green Sheeting clip is being used- to sheet/gown?
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Drain tube and bag below bladder?
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Bag/Meter is not touching floor?
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System labeled with insertion information?
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Device Insertion Location
- ED
- OR
- ICU
- MS
- PCU
- other
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# Foley days?
