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In addition to knowing how to perform urinalysis, itβs also important to understand how to appropriately document the results of urinalysis in a patientβs notes. This guide provides a structured approach to documenting urinalysis results in a patientβs notes.
Documentation basics
Before we discuss how to document urinalysis results, we need to cover the basics that apply to all documentation in a patientβs notes. You can check out our detailed guide to writing in the notesΒ for more information.
What should I use to write with?
You need to use a pen withΒ blackΒ 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 patientβs current location on the continuation sheet:
- Hospital
- Ward
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.Β Adding the date and time (in 24-hour format) of your entry.
2.Β Writing your name and role as an underlined heading.
3.Β Adding your entry in the notes below this heading (see the next section for details).
Documenting the urinalysisΒ results in the notes
1. Document the time and date that the urinalysisΒ was performed (as this may be significantly different from the time you are documenting).
2. Write the indication for the urinalysisΒ (e.g. dysuria).
3. Inspect the urine and document the following characteristics of the urine:
- Colour
- Clarity
4. Document the urinalysis resultsΒ (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 canΒ 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.
Completing the entry in the notes
At theΒ end of your entryΒ to need toΒ includeΒ theΒ 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)