11/13/24, 7\:41 PM Guide | Documenting urinalysis

Documenting urinalysis

Table of contents

Introduction

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
Full name
Date of birth
Unique patient identi
Home address
If a patient label containing at least three identi
manually.

Location details

You should indicate the patient’s current location on the continuation sheet\:
Hospital
Ward
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Patient identi

Beginning your entry

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 identi
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).
Starting your entry in the notes
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Documenting the urinalysis results

1. Document the time and date that the urinalysis was performed (as this may be signi
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
Speci
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.
t r a c t i n f e c t i o n" ).
" b l o o d a n d n i t r i t e s p o s i t i v e , i n k e e p i n g w i t h a d i a g n o s i s o f u r i n a r y
6. Document your plan based on the urinalysis
Documenting urinalysis results
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Completing the entry

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)
Source\: geekymedics.com
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