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:
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