In addition to knowing how to perform urinalysis, it’s also important to understand how to appropriately document urinalysis results in a patient’s notes. This guide provides a structured approach to documenting urinalysis results in a patient’s notes, with included examples.
Before we discuss how to document the urinalysis itself, 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 here 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).
For every new sheet of paper your first task should always be documenting at least three key identifiers for a patient:
- Full name
- Date of birth
- Unique patient identifier
- Patient’s home address
If a patient label containing at least 3 identifiers is available then this can be used instead of writing out the information yourself.
You should indicate the patient’s location on the continuation sheet:
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.
1. Add the date and time (in 24hr format) of your entry
2. Write your name and role as an underlined heading
3. Make your entry in the notes below this heading (see the next section for details)
Documenting the urinalysis results in the notes
1. Document the time and date that the urinalysis was performed (as this may be significantly different than the time you are documenting)
2. Write the indication for the urinalysis (e.g. dysuria)
3. Inspect the urine and document:
- Colour of urine
- Clarity of urine
- Odour of urine (e.g. offensive)
4. Document the urinalysis results (see our guide to performing urinalysis here):
- pH – indicates acidity of urine – e.g. ↓pH in systemic acidosis
- Specific gravity – indicates amount of solute dissolved in urine – ↓ in diabetes insipidus
- Blood – indicates number of red blood cells in urine – ↑ in haematuria
- Protein – indicates level of protein in the urine – ↑ nephrotic syndrome
- Leukocyte esterase – enzyme produced by neutrophils (WCC in urine) – ↑ in UTI
- Nitrites – breakdown products caused by Gram -ve organisms – Gram -ve UTI e.g. Ecoli
- Ketones – breakdown product of fatty acid metabolism – ↑ starvation / ↑DKA
- Glucose – ↑ hyperglycaemia e.g. poorly controlled diabetes
- Bilirubin – Indicates ↑ conjugated bilirubin (water soluble) – ↑ biliary tract obstruction
- Urobilinogen – if raised indicates ↑ bilirubin turnover – ↑malaria / ↑haemolytic anaemia
If any of the results are abnormal you should highlight them, either by underlining them 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 nitrite 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 the end of your entry to need to include the following:
- Your full name
- Your grade/role (e.g. Medical student/F2/Renal registrar)
- Your signature
- Your professional registration number (e.g. GMC number)
- Your contact number (e.g. phone/bleep)