Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Evaluation and management of CAUTI.
SOAP
Subjective (S):
Urinary Symptoms:
Inquire about any recent changes in urinary habits or symptoms, such as:
Burning or pain with urination (dysuria)
Frequent urination (urgency)
Blood in the urine (hematuria)
Urinary incontinence
Catheter History:
Investigate the type of urinary catheter (e.g., Foley catheter) and duration of placement.
Explore for any recent changes in catheter care practices.
Past Medical History:
Briefly summarize relevant past medical history, including:
Previous episodes of UTIs
Underlying conditions that might increase susceptibility to CAUTI (e.g., diabetes, immunosuppression)
Recent hospitalization or surgeries requiring urinary catheterization
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate. Assess for fever or other signs of systemic infection.
Physical Exam:
Perform a focused physical exam to assess for:
Costovertebral tenderness (flank pain) suggesting kidney involvement
Lower abdominal tenderness
Signs of dehydration (e.g., dry mucous membranes)
Urinalysis and Urine Culture:
Report the results of urinalysis (presence of leukocytes, nitrites, blood) and urine culture (identifying the specific organism and antibiotic sensitivities).
Assessment (A):
Diagnosis:
Based on clinical presentation, urinalysis findings, and positive urine culture, confirm the diagnosis of CAUTI.
Catheter-associated:
Emphasize that the UTI is catheter-associated based on the presence of an indwelling urinary catheter.
Organism and Sensitivities:
Identify the specific microorganism causing the CAUTI and its antibiotic sensitivities.
Severity:
Briefly describe the severity of CAUTI based on symptoms and presence of systemic inflammatory response.
Plan (P):
Antibiotic Treatment:
Initiate appropriate antibiotic therapy based on urine culture sensitivities and local antibiotic stewardship guidelines.
Consider duration of treatment based on severity of CAUTI.
Catheter Management:
Evaluate catheter necessity: Determine if the urinary catheter can be safely removed.
Catheter care optimization: If the catheter remains necessary, emphasize the importance of aseptic technique during catheter manipulation and routine care to prevent recurrent infections. Consider using a closed drainage system and maintaining a sterile field.
Hydration:
Encourage adequate fluid intake to promote urine output and flush out bacteria.
Re-evaluation:
Schedule a follow-up visit to assess response to treatment and consider catheter removal if possible.
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., infectious disease)
Need for additional testing (e.g., imaging studies to rule out complications)
Implementation of infection control measures to prevent further CAUTI spread
Patient education regarding importance of catheter care and signs/symptoms of recurrent UTI