Urinary Renal

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General Section

SKILLED DOCUMENTATION GUIDELINES — EXPANDED

DiraChart · Clinical Reference · Read-only baseline inherited by all agencies

Body System Reference · 2.23

Urinary / Renal

Bladder and kidney function and the devices that support them. Diagnoses commonly routed here: urinary tract infection, urinary retention, incontinence, indwelling/intermittent/suprapubic catheter management, chronic kidney disease and acute kidney injury, and fluid-balance disturbance. Renal-diet teaching is shared with Nutrition; cardiorenal fluid overload is shared with the Heart Failure overlay; catheter as a device is shared with Lines/Drains/Devices; hematuria on anticoagulation is shared with the Anticoagulation overlay.

Module code

SYS-URINARY-RENAL

Version

1.0 · Population: Adult · Authoring level: DiraChart (read-only baseline; agencies may append)

Used alongside

Hydration · Heart Failure overlay (cardiorenal / fluid) · Nutrition (renal diet) · Lines / Drains / Devices (catheter) · Anticoagulation overlay (hematuria) · Vital Signs

How to use this module

This module supplies the complete urinary and renal assessment — voiding and continence, catheter management, infection recognition, fluid balance, and the signs of renal dysfunction — and the skilled language that proves it required a licensed nurse. Renal-diet detail is documented in Nutrition, cardiorenal overload in the Heart Failure overlay, and catheter device-management technique cross-references Lines/Drains/Devices. Each narrative is a structured example to edit to the actual visit and the patient’s orders — not a phrase to copy.

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