Select date

Pt ID? Room #?


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?

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.