530 An Audit of Appropriate Documentation Following Urethral Catheterisation

نویسندگان

چکیده

Abstract Introduction Urethral catheterisation is a procedure frequently done in the hospital by medical personnel. Appropriate documentation necessary to ensure safe clinical care and reduce risk of litigation. Method We randomly reviewed electronic notes patients seen on-call urology team who had urethral catheter inserted September 2020. Reviewing trust’s guidelines, we considered that appropriate should include reference following 10 items; indication, chaperone present, consent obtained, groin examination, size, type, insertion process, urine colour, water balloon residual volume were reviewed. Results A total 50 included. 72%(36/50) member team. Only 28%(14/50) all items documented. Indication for was best documented at 94%(47/50) while presence examination (i.e. foreskin its replacement post-catheterisation) lowest 44%(22/50). Conclusions This study shows there low compliance adequate catheterisation. ‘smart phrase’ has been developed use with our Trusts records system assist clinicians documentation. Clinicians phrase ‘.icat’ are prompted document requisite items. uses mnemonic i-CATHETAR [indication, Chaperone consent, Assessment, Tube (catheter size type), process (Hard/Easy), Tint, Aqua balloon, Residual volume]. second audit cycle currently being review effectiveness this intervention.

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ژورنال

عنوان ژورنال: British Journal of Surgery

سال: 2021

ISSN: ['1365-2168', '0007-1323']

DOI: https://doi.org/10.1093/bjs/znab259.063