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  • XX y.o. fe/male admitted xx/xx/202x
  • Admission diagnosis:
  • Recent procedures/surgery:

UNIT XX/XX/2X

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UNIT XX/XX/2X

  • Foley Insertion and Location:

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Foley Insertion Date

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Location of Insertion

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Level of Inserter

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Was there an order for the Foley?

Was there a “do not remove” order?

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Foley Indication

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Diuretics

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Days to Infection

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Was Foley in place at time of Infection?

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UNIT XX/XX/2X

  • Infection Details:

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Information

XX/XX/XX

XX/XX/XX

XX/XX/XX

XX/XX/XX

XX/XX/XX

XX/XX/XX

XX/XX/XX

UA

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Urine Culture

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Reason for Culture

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Foley Replacement/Insertion

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Blood Culture

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Symptom

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4 of 5

UNIT XX/XX/2X

Provider Feedback

  • Was Foley necessary? Yes/No
  • Were UA/Urine culture necessary? Information related to treatment
  • Any other contributing factors?
    • Any additional comments

5 of 5

UNIT XX/XX/2X

Nursing Feedback

  • Any missed opportunities for pericare/Foley care? Yes/No
  • Was the drainage system opened at any point? Yes/No
  • Were there any problems with equipment/supplies? List any issues/None
  • Potential contributing factors?
    • Any additional comments

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Opportunity: