ࡱ> a ttbjbjڥڥ 7xR\R\R  VVVVVjjj8DTj!:PPPP+++%!'!'!'!'!'!'!$n#$&K!9V+++++K!VVPP!+vVPVPp+%!Pеh}(!0!&v&&V+++++++K!K!?+++!++++&+++++++++ > : Catheterization Care Documentation Record (page 1 of 2) Complete Nursing Assessment & Interventions in Accordance with Individualized Health Care Plan (IHCP) Nursing Goal: Maintain integrity of urinary tract, prevent urinary tract infection, prevent incontinence, and foster student independence Student Name DOBSchool/ District GradeParent/ Guardian PhonePhysician/ NP/PA PhoneOrder Start DateOrder Exp DateIHCP on FileICD-10 Code __ __ __ __ __ Type of Catheter: m ( Indwelling m ( In & Out catheter m ( Suprapubic Latex Allergy: m (Yes (No Date/TimesCatheterization CareComplications/AssessmentSignature/Title*Code Date Start Time Stop TimeComplete procedure per medical orders & follow universal precautionSelf- Catheter- ization Yes NoNote amount of urine obtained S & Sx Infection1 *Medication Administration Procedure Code: CPT T1002 = RN services up to 15 min. or CPT T1003 = LPN services up to 15 min. To be completed by Attending Provider (School Nurse/RN): NOTE: LPN must use supervising RNs NPI number Name: ______________________________________ Title: _______ NPI number: ___ ________ Name: ______________________________________ Title: _______ NPI number: ___ ________ Name: ______________________________________ Title: _______ NPI number: ___ ________ Name: ______________________________________ Title: _______ NPI number: ___ ________ 1 -c=cloudy urine, f=foul odor, b=bloody urine, c=chills, fe=fever, p=painful urination, fl=flank pain/tenderness, n/v=nausea/vomiting Student Name:_________________________________________DOB:________________ Page 2. 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