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Expert spotlight: Electronic documentation elements for CAUTI patients

Nurse Leader Weekly, May 18, 2009

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This week, June Marshall, RN, MS, NEA-BC, Lucy Bird, RN, and Laura Maverick, BSN, RN-BC, provide guidelines for using electronic documentation tools to assess patients for catheter-associated urinary tract infections (CAUTIs).

Q: My facility will soon be adopting an electronic documentation system that will allow nurses to input information into patients’ health records. What elements should my staff assess in regard to patients at risk for CAUTIs?

A: Electronic documentation systems are not always customized to support thorough documentation of insertion, continuation, care, and removal of indwelling urinary catheters. This can make it difficult when reviewing records to gather information about patients with documented CAUTIs, including accurately determining catheter days from various methods nurses used to document the presence of patients’ indwelling urinary catheters. In addition, some systems do not provide a place for nurses to document the rationale for placement, continuation, and/or removal of the catheter or consistent evidence of the size and type of catheter or the type and frequency of perineal care provided for patients with indwelling urinary catheters.

Important elements of documentation in patients at risk for CAUTI include the following:

• Healthcare provider order to place/continue/remove the catheter with accompanying rationale for indwelling urinary catheter placement/continuation/removal
• Expected length of catheter use as a determinant of catheter choice and drainage system selection
• Presence of relevant comorbid conditions, such as diabetes, immunosuppression, urologic surgery, spinal cord injuries (or other neurologic diagnoses that affect urinary tract function), and previous history of urinary tract infection (UTI)
• Date and time of insertion/removal as well as size and type of urinary catheter inserted/removed
• Date, time, and type of perineal/meatalcare provided
• Evidence of signs and symptoms of UTI
• Evidence of diagnosis and treatment of symptomatic CAUTI

Editor’s note: Do you have a question for our experts? Email your queries to Editor Keri Mucci at kmucci@hcpro.com and see your name in print next week! In the meantime, head over to our Web site and view a growing collection of advice from our experts.

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