Title Page

  • Document No.

  • Prepared by

  • Select date

  • Pt ID? Room #?

  • Sex?

  • Reason for catheter

  • Catheter Type

  • Red Tamper-evident Seal Present and intact?

  • Foley Catheter Secured to patient?

  • If yes, Type of securement?

  • 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

  • # Foley days?

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.