Documentation of Foley catheter care is a mandatory clinical practice serving multiple purposes. Charting provides a clear, official record for communication among the healthcare team, ensuring continuity of care and a shared understanding of the patient’s condition. Accurate and timely documentation also acts as a legal record, safeguarding both the patient and the care providers. This process is fundamental for quality assurance, allowing for the monitoring of care standards and the prompt identification of potential safety issues, such as a Catheter-Associated Urinary Tract Infection (CAUTI).
Documentation of Routine Catheter Maintenance
Charting the routine physical care of the indwelling catheter is essential for preventing infection and discomfort. Documentation must specify the frequency and method of perineal hygiene, which typically involves cleaning the area around the meatus with mild soap and water during daily bathing. Recording that this care was performed helps ensure that a standardized infection prevention protocol is consistently followed.
The assessment of the insertion site skin integrity must also be noted clearly in the medical record. This charting includes a description of the urethral meatus and surrounding tissue, noting the absence of common complications like redness, swelling, or any unusual discharge. Documenting a securement device’s integrity and placement is equally important to prevent urethral trauma caused by traction or movement.
The record should confirm that the catheter is properly secured to the patient’s thigh or abdomen to prevent tension on the urethra. A clear note must also be made regarding the patency of the drainage system, confirming that the tubing is free of kinks or dependent loops that could obstruct urine flow. This documentation confirms that mechanical aspects are maintained to support proper drainage and minimize the risk of ascending infection.
Charting Urinary Output and Drainage Assessment
Accurate measurement and recording of the patient’s urinary output is a primary function of indwelling catheters and must be charted as part of the Intake and Output (I&O) record. The volume of urine drained is measured and recorded at specified intervals, often every shift, to allow for precise fluid balance assessment. Documentation must also include a detailed description of the urine’s characteristics, which offers immediate insight into the patient’s hydration and potential complications.
Specific charting language is used to describe the urine’s appearance, such as “straw-colored” or “amber” for color, and “clear” or “cloudy” for clarity. Any presence of sediment, hematuria (blood), or a noticeable odor must be objectively noted as these can be early indicators of infection or other pathology. The collection bag must remain below the level of the bladder to prevent the backflow of urine, which increases the risk of CAUTI. The time and volume when the drainage bag was emptied must also be recorded to track the continuous flow of urine and maintain a closed system.
Recording Abnormal Findings and Interventions
Any signs suggestive of a Catheter-Associated Urinary Tract Infection (CAUTI) must be immediately recorded with objective detail. This includes charting systemic symptoms like fever or chills, localized symptoms such as flank or suprapubic pain, and any acute changes in mental status, particularly in elderly patients.
Documentation is also required for mechanical problems, such as catheter blockage or a sudden absence of urine output (anuria or oliguria). The record must detail any attempts to troubleshoot the issue, such as checking for kinks or flushing the catheter, and the patient’s response to these actions. In the event of an accidental or intentional catheter removal, the time of the event, the patient’s condition, and the status of the removed catheter must be charted.
Documentation of abnormal findings must include the intervention steps and the reporting chain. The record must specify who was notified—such as the physician or nurse practitioner—the exact time of the notification, and a summary of any orders received. For example, a note detailing a CAUTI might read: “Patient reports severe suprapubic pain, temperature 101.5 F. Dr. Smith notified at 14:30. Ordered urine culture and catheter change.” This provides a complete and legally defensible account of the response to the patient safety concern.