Use when urinary and renal status is at the patient’s baseline under the current order. Fill the bracketed blanks with the visit’s actual findings; the clinical findings are not changed — the reasoning a layperson cannot supply is added. The skilled rationale supports the record when it is accurate, individualized, consistent with the plan of care, and tied to the findings, orders, and patient response documented during the actual visit.
Skilled urinary and renal assessment completed. Voiding [pattern/volume] at baseline, [no] dysuria, urgency, or retention; urine [color/clarity], [no] odor or hematuria. [Catheter type] patent and draining [output], secured correctly, insertion/stoma site [intact]. No suprapubic distension or tenderness; [post-void residual where assessed]. No infection signs; mental status at the patient’s cognitive baseline. Fluid balance [weight vs target], edema [stable/absent]; intake and output [where ordered]. The assessment of urine, catheter function, and fluid status against baseline confirms stability and continued appropriateness of the fluid and medication order; [catheter care / fluid-target / infection-warning] teaching reinforced with the patient/caregiver, who [teach-back result].
Short form
Skilled GU/renal assessment: voiding at baseline, no dysuria/retention; urine clear, no hematuria; [catheter] patent, site intact; no suprapubic distension; no infection signs, mental status at baseline; weight [vs target], edema stable. Fluid/med plan continued. [Catheter care/fluid] teaching reinforced, teach-back correct.
