Healthcare Urinary Retention Protocol

HEALTHCARE URINARY RETENTION PROTOCOL

Patient Information

Patient Name:

Date of Birth:    Gender:    Medical Record #:

Insurance / Billing

Relevant Medical History

Assessment / Presentation

Time of assessment:    Bladder scan volume:    Post-void residual (PVR):

Symptoms observed (check all that apply):

Inability to void Urgency / suprapubic pain Retention following surgery/anesthesia Concern for renal impairment

Indications for Catheterization (Orders)

Indication(s) — clinician to check applicable boxes and provide parameters:

Acute urinary retention Bladder scan volume greater than

Post-operative urinary retention Neurogenic bladder with retention Other (specify)

Catheter and Procedure Orders

Catheter type (check one):

Indwelling (Foley) Intermittent catheterization External catheter (male condom)

Sterile technique Clean technique Local anesthetic as indicated

Obtain urine culture at insertion Urinalysis

Irrigation ordered: Yes No    If yes, solution and frequency:

Monitoring and Care

Urine output monitoring frequency:    Catheter care schedule:

Bladder scan schedule for reassessment:

Contraindications / Precautions

Latex allergy: Yes No

Clinician precautions / notes:

Risks, Benefits, and Alternatives

I hereby acknowledge that the clinician has explained the urinary catheterization procedure, the clinical rationale for catheterization, expected benefits, and reasonable alternatives including bladder scanning, intermittent catheterization, timed voiding, and external devices. I understand the potential risks include, but are not limited to: urinary tract infection, urethral trauma, hematuria, urethral stricture formation, catheter malfunction, allergic reactions to catheter materials, and systemic infection. I understand attempts will be made to minimize risk through sterile technique and appropriate equipment selection.

Emergency and Complication Management

If complications occur (significant bleeding, inability to pass catheter, severe pain, signs of sepsis), staff will initiate appropriate interventions including removal of catheter if indicated, urology consultation, hemodynamic support, and escalation of care. Any suspected infection will be managed according to institutional infectious disease procedures.

Authorizing Clinician Orders

Date of order:

Authorization, Confidentiality, and Acknowledgment

Authorization: By signing below, I authorize designated clinical staff to perform bladder catheterization and related procedures as ordered above. I understand this authorization includes insertion, maintenance, collection of urine specimens, and removal of catheter when clinically indicated. I understand I may refuse or withdraw consent at any time before the procedure and that declining catheterization may carry clinical risks associated with untreated urinary retention.

Confidentiality: I acknowledge that information related to this procedure and my health will be maintained in my medical record in accordance with applicable privacy regulations. I consent to the release of procedure-related information to other clinicians for purposes of my care.

Authorization expires on:

I certify that I have had the opportunity to ask questions about the procedure, the risks and benefits, and reasonable alternatives. My questions have been answered to my satisfaction.

Patient / Representative acknowledges HIPAA notice and privacy protections: I acknowledge

Patient Statement

Sign Now