Toronto Rehabilitation Institute

THC TLC TQEC TRC TUC

INDWELLING CATHETER INSERTION RECORD

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First insertion date: ______

Reason for insertion: ______

______

Is there a need for irrigation? yes no

If yes, give reason:______

(must be reassessed q7days)

Frequency ordered: ______

DATE

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OUT

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IN

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Signature

Cath size / Balloon size / Reason for removal / Cath size / Balloon size / Type of catheter / Deflate/re-inflate date

When a catheter is discontinued, 2 post void residuals via Bladder Scan Ultrasound are required to ensure patient empties bladder.

# 1 amount:______Date: ______# 2 amount: ______Date: ______

DATE

/

OUT

/

IN

/

Signature

Cath size / Balloon size / Reason for removal / Cath size / Balloon size / Type of catheter / Deflate/re-inflate date

When a catheter is discontinued, 2 post void residuals via Bladder Scan Ultrasound are required to ensure patient empties bladder.

# 1 amount:______Date: ______# 2 amount: ______Date: ______

1

Form #243 revised: Aug.02