Catheter Audit Documentation

V 2.0

Introduction

Resident Selection

Residents Included

All current residents with an active physician order for ANY urinary catheter, catheter care, or a Nephrostomy Tube (found in the “Orders“ tab on PCC’s front end).

Business Rules

Tasks:

1. Diagnosis Tab - Diagnosis supporting the use of a catheter is present in the EMR. (Q1602)

   1. Location in PCC:

      1. Diagnosis (Med Diag tab)

   2.  Business Rule:

      1. IF a resident has an active order for a catheter,
         AND the order is for an Indwelling or External catheter,
         OR  the order is for a Nephrostomy Tube, 
         THEN there must be a diagnosis that justifies the use of a catheter. 
         These include:

         1. Neurogenic bladder

         2. Obstructive Uropathy

      2. IF a resident has an active order for a catheter,
         AND the order is for an Intermittent catheter, 
         THEN there must be a diagnosis that justifies the use of a catheter. 
         These include:

         1. Neurogenic bladder

         2. Obstructive Uropathy

         3. Retention of Urine

   3. Due Date:

      1. Within 24 Hours of the order date

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the catheter order is no longer active

2. Order must contain Diagnosis - Physician Must Fill Out Order Properly, Including Diagnosis (Q1601)

   1. Location in PCC:

      1. Orders

   2. Business Rule:

      1. IF a resident has an active physician order for a catheter,
         AND the order is for an Indwelling or External catheter,
         THEN the physician order must contain a qualifying diagnosis
         These include:

         1. Neurogenic Bladder

         2. Obstructive Uropathy

         3. Neuromuscular Dysfunction

         4. Paraplegia or Quadriplegia

      2. IF a resident has an active physician order for a catheter,
         AND the order is for an Intermittent catheter,
         THEN the physician order must contain a qualifying diagnosis
         These include:

         1. Neurogenic Bladder

         2. Obstructive Uropathy

         3. Neuromuscular Dysfunction

         4. Paraplegia or Quadriplegia

         5. Retention of Urine

   3. Due Date:

      1. Within 24 Hours of the order date

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the catheter order is no longer active

3. Order Size - Physician Must Fill Out Order Properly, Including Catheter Size (Q1607)

   1. Location in PCC:

      1. Orders

   2. Business Rule:

      1. IF a resident has an active physician order for a catheter,
         AND the order is for an Indwelling Catheter
         AND the order is NOT for a Nephrostomy Tube,
         THEN the physician order must indicate the size of the catheter

   3. Due Date:

      1. Within 24 Hours of the order date

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the catheter order is no longer active

4. Order for Drainage Bag - Physician Must Fill Out Order for Drainage Bag (Q1608)

   1. Location in PCC:

      1. Orders

   2. Business Rule:

      1. IF a resident has an active physician order for a catheter,
         AND the order is for either an Indwelling or External Catheter
         THEN there must be a physician order indicating use of a drainage bag.

   3. Due Date:

      1. Within 24 Hours of the order date

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the catheter order is no longer active

5. Order for Catheter Care - Physician Must Fill Out Order for Catheter Care (Q1609)

   1. Location in PCC:

      1. Orders

   2. Business Rule:

      1. IF a resident has an active physician order for a catheter,
         THEN there must be a physician order for catheter care

   3. Due Date:

      1. Within 24 Hours of the order date

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the catheter order is no longer active

6. Care Plan Diagnosis - Care plan in place to address catheterization includes qualifying diagnosis (Q1605)

   1. Location in PCC:

      1. Care Plan

         1. Focus

   2. Business Rule:

      1. IF a resident has an active order for a catheter,
         THEN there must be a care plan addressing the catheter,
         AND the Focus of the care plan must include a relevant diagnosis justifying the use of a catheter. (see question 6 for justifying diagnoses)

   3. Due Date:

      1. Within 24 Hours of the order date OR

      2. 3 weeks after admission for new residents

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the catheter order is no longer active

7. Care Plan Risk Factors - Care plan in place to address catheterization includes Risk Factors (Q1612)

   1. Location in PCC:

      1. Care Plan

         1. Interventions

   2. Business Rule:

      1. IF a resident has an active order for a catheter,
         THEN there must be a care plan addressing the catheter,
         AND the Interventions of the care plan must include observation of Risk Factors such as infection, pain, or trauma.

   3. Due Date:

      1. Within 24 Hours of the order date OR

      2. 3 weeks after admission for new residents

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the catheter order is no longer active

8. Care Plan UTI Preventions - Care plan in place to address catheterization includes UTI prevention. (Q1615)

   1. Location in PCC:

      1. Care Plan

         1. Interventions

   2. Business Rule:

      1. IF a resident has an active order for a catheter,
         AND the order is for an Indwelling or External catheter,
         THEN there must be a care plan addressing the catheter,
         AND the Interventions of the care plan must include UTI prevention measures such as: 

         1. cath care

         2. monitoring for infection

         3. fluids

   3. Due Date:

      1. Within 24 Hours of the order date OR

      2. 3 weeks after admission for new residents

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the catheter order is no longer active