How to Document Urinalysis Results in the Notes

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In addition to knowing how to perform urinalysis, it’s also important to understand how to appropriately document the results of urinalysis in a patient’s notes. This guide provides a structured approach to documenting urinalysis results in a patient’s notes.


Documentation basics

Before we discuss how to document urinalysis results, we need to cover the basics that apply to all documentation in a patient’s notes. You can check out our detailed guide to writing in the notes for more information.

What should I use to write with?

You need to use a pen with black ink, as this is the most legible if notes are photocopied.

Patient details

For every new sheet of paper your first task should be to document at least three key identifiers for the relevant patient:

  • Full name
  • Date of birth
  • Unique patient identifier
  • Home address

If a patient label containing at least three identifiers is available, then this can be used instead of writing out the information manually.

Location details

You should indicate the patient’s current location on the continuation sheet:

  • Hospital
  • Ward
Patient identifiers
Patient identifiers

Beginning your entry in the notes

At this point, you should already be holding a pen with black ink and you should have ensured the continuation sheet has at least three key patient identifiers at the top.

The next documentation steps include:

1. Adding the date and time (in 24-hour format) of your entry.

2. Writing your name and role as an underlined heading.

3. Adding your entry in the notes below this heading (see the next section for details).

Beginning an entry
Beginning an entry

Documenting the urinalysis results in the notes

1. Document the time and date that the urinalysis was performed (as this may be significantly different from the time you are documenting).

2. Write the indication for the urinalysis (e.g. dysuria).

3. Inspect the urine and document the following characteristics of the urine:

  • Colour
  • Clarity

4. Document the urinalysis results (see our guide to performing and interpreting urinalysis):

  • pH
  • Specific gravity
  • Blood
  • Protein
  • Leukocyte esterase
  • Nitrites
  • Ketones
  • Glucose
  • Bilirubin
  • Urobilinogen

If any of the results are abnormal you should highlight them, either by underlining or circling them. You can also indicate with an arrow whether the result is abnormally high or low.

5. Document your overall impression of the urinalysis (e.g. “blood and nitrites positive, in keeping with a diagnosis of urinary tract infection”).

6. Document your plan based on the urinalysis findings.

Documenting urinalysis, impression and plan
Documenting urinalysis, impression and plan

Completing the entry in the notes

At the end of your entry to need to include the following:

  • Your full name
  • Your grade/role (e.g. F2/Medical Registrar)
  • Your signature
  • Your professional registration number (e.g. GMC number)
  • Your contact number (e.g. phone/bleep)
Completed documentation
Completed documentation

 

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