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.
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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 blackink, as this is the most legible if notes are photocopied.
For every new sheet of paper your first task should be to document at least three key identifiers for the relevant patient:
Date of birth
Unique patient identifier
If a patient label containing at least three identifiers is available, then this can be used instead of writing out the information manually.
You should indicate the patient’s current 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.
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).
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: