13
Urinary Catheter Reminder
Date: ___/___/______
This patient has had an indewelling urethral catheter since ___/___/______
Please indicate below EITHER (1) that the catheter should be removed OR
(2) that the catheter should be retained. If the catheter should be retained, please
state ALL of the reasons that apply.
❑ Please discontinue indwelling urethral catheter; OR
❑ Please continue indwelling urethral catheter because patient requires
indwelling catheterization for the following reasons (please check ALL that
apply):
❑ Urinary retention
❑ Very close monitoring of urine output and patient unable to use urinal
or bedpan
❑ Open wound in sacral or perineal area and patient has urinary
incontinence
❑ Patient too ill or fatigued to use any other type of urinary collection
strateg y
❑ Patient had recent surgery
❑ Management of urinary incontinence on patient's request
❑ Other — please specify:
