How to write note for urinary catheter insertion ip patient
Reading File
Finding Sources
Searching the Web
how to write procedure note urinary catheter insertion inpatient nursing documentation
Reading Web Page
procedure note urinary catheter insertion documentation sample
Here is a complete guide to writing a procedure note for urinary catheter insertion in an inpatient (IP) setting.
Procedure Note: Urinary Catheter Insertion (Inpatient)
A procedure note is written immediately after insertion. It should be concise, factual, and include all elements below.
Standard Format
Date / Time:
Write the exact date and time of insertion (e.g., 29/06/2026, 10:15 AM).
Indication:
State the clinical reason. Common examples:
- Urinary retention (acute/chronic)
- Strict intake-output monitoring (ICU, post-op, oliguria)
- Immobility / bed rest
- Pre-operative / intra-operative requirement
- Urological procedure or surgery
Patient Identification:
Confirm two identifiers checked (name + date of birth / MRD number).
Informed Consent:
- Procedure explained to patient / attendant
- Patient verbalized understanding / consent obtained
Pre-procedure Assessment:
- Allergies checked (latex, iodine/Betadine, adhesives)
- Any orthopedic limitations noted
- Previous urological surgeries or strictures noted
- Bladder distension assessed (palpation or USG)
Equipment Used:
- Catheter type: Foley (indwelling) / straight (in-out)
- Catheter size (French): e.g., 14 Fr, 16 Fr, 18 Fr
- Balloon volume: 10 mL sterile water (standard)
- Drainage bag attached: Yes / No
Procedure:
- Aseptic / sterile technique maintained
- Genital area cleaned with antiseptic solution (Betadine/chlorhexidine)
- Sterile draping applied
- Lubricating gel instilled (e.g., lignocaine gel 2%)
- Catheter inserted without / with difficulty
- Balloon inflated with ___ mL sterile water without resistance
- Catheter secured to thigh with adhesive / stat-lock
Outcome:
- Urine drained: Yes / No
- Amount of urine drained: ___ mL
- Urine color: clear / pale yellow / dark amber / blood-tinged / cloudy
- Urine odor: normal / foul
- Sediment: present / absent
Patient Tolerance:
- Patient tolerated procedure well
- Complaints of discomfort: Yes / No
- Any complications: Yes / No (specify if yes)
Post-procedure Instructions:
- Drainage bag kept below bladder level at all times
- Tubing coiled loosely without kinks
- Patient/attendant instructed to report: bladder pain, burning, spasms, hematuria, fever
- Catheter care (pericare) explained
Signature:
Name, designation, date, time.
Sample Completed Note
Date/Time: 29/06/2026 at 0930 hrsProcedure: Insertion of indwelling urinary catheter (Foley catheter)Indication: Acute urinary retention - patient unable to void since 6 hours, suprapubic distension present.Consent: Procedure explained to patient and attendant. Consent obtained verbally.Allergies: No known allergy to latex or Betadine.Procedure: Under strict aseptic precautions, genital area cleaned with Betadine solution. Sterile draping applied. Lignocaine gel 2% instilled per urethra. An 18 Fr two-way Foley catheter inserted per urethra without difficulty. Balloon inflated with 10 mL sterile water. No patient discomfort on balloon inflation. Catheter secured to right inner thigh. Drainage bag connected and positioned below bladder level.Outcome: 450 mL of clear, pale yellow urine drained immediately. No hematuria or foul odor. Patient reports relief of suprapubic pressure.Patient Condition: Tolerating procedure well. Vitals stable. No immediate complications.Instructions given: Patient and attendant educated regarding catheter care, bag position, and signs of infection.Signature: [Name], [Designation], Ward __, Bed __, Date/Time
Key Points to Remember
| Element | What to Record |
|---|---|
| Catheter size | Always note Fr size (14F, 16F, 18F, etc.) |
| Balloon volume | Standard is 10 mL sterile water |
| Urine output | Exact volume + color + odor + sediment |
| Difficulty | Note if multiple attempts, stylet used, or senior called |
| Complications | Bleeding, false passage, failed attempt must be documented |
| CAUTI prevention | Note sterile technique maintained - important for infection audit |
If Insertion Was Difficult
Add a note like:
"First attempt unsuccessful due to resistance. Catheter withdrawn, additional lubricant applied, catheter re-inserted successfully on second attempt. Urology team informed."
If Catheterization Failed
Document clearly:
"Urethral catheterization attempted twice without success. Resistance encountered, likely urethral stricture. Urology team notified. Suprapubic catheterization to be considered."
This format covers nursing notes, resident/doctor procedure notes, and medicolegal documentation requirements. The note should always be written in the patient's medical record immediately after the procedure.
This is a shared conversation. Sign in to Orris to start your own chat.