Related Experiment Video
Updated: May 29, 2026
An In Vitro Bladder Model of Catheter-Associated Urinary Tract Infection
Published on: June 24, 2025
Quality of documentation of urethral catheterization in a Nigerian teaching hospital
K H Tijani1, A O Lawal, R W Ojewola
1Urology Unit, Department of Surgery, College of Medicine, University of Lagos, Lagos State. habeeb_tijani@yahoo.com
Insights
Documentation of urethral catheterization is poor, especially in medical notes compared to nursing records. This inadequate record-keeping impacts patient care and has medico-legal implications, necessitating improved protocols.
Area of Science:
- Urology
- Healthcare Quality Improvement
- Medical Documentation
Background:
- Urethral catheterization is a common procedure with potential severe complications.
- Inadequate procedural records hinder effective management of catheterization complications.
- Lack of detailed documentation poses challenges for patient care and medico-legal review.
Purpose of the Study:
- To assess the quality of documentation for urethral catheterization procedures.
- To identify areas of deficiency in medical and nursing records related to catheterization.
- To evaluate the adherence to documentation standards within the institution.
Main Methods:
- Prospective study conducted over one month.
- Assessment of medical and nursing records using 10 parameters and a pro-forma.
- Statistical analysis performed using the Wilcoxon signed ranks test.
Main Results:
- Overall documentation quality was poor across 89 catheterized patients.
- Medical notes showed significantly worse documentation than nursing records (28% discrepancy).
- Aseptic technique documentation was absent in all cases; 11% incidence of complications noted.
Conclusions:
- Record-keeping for urethral catheterization is inadequate, affecting patient care and medico-legal aspects.
- Recommendations include regular audits and implementation of standardized documentation protocols.
- Improving documentation is crucial for enhancing patient safety and clinical accountability.
Background:
Urethral catheterization is a common minimally invasive procedure with well-known complications some of which may be severe. Quite often, a clinician is invited to manage the short and long-term complications of the procedure without adequate records of the procedure itself.
Objectives:
This study aims to determine the quality of documentation of urethral catheterization in our health institution.
Methods:
This prospective study was carried out over a period of 1 month. The documentations in the medical notes and nursing records with respect to urethral catheterisation were assessed using 10 different parameters with the aid of a pro-forma. Statistical analysis was done with the Wilcoxon signed ranks test.
Results:
A total of 89 patients were catheterised in the wards, the emergency departments and the theatre. All the catheterizations were performed by doctors. The overall quality of documentation of catheterisation was poor: It was significantly worse in the medical notes than the nursing records with 28% of all cases documented by the nurses not documented by the physicians. Documentation in the theatre and emergency were worse, while there was no documentation of aseptic technique in any patient. An 11% incidence of complications was noted.
Conclusion:
The quality of record keeping concerning urethral catheterization was inadequate. This is important not only for patients' care, but also for medico-legal purposes. We therefore recommend regular audit and introduction of protocols for proper documentation.
Related Concept Videos
01:30Guidelines for Nursing Documentation I
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
01:30Urinary Tract Infection III: Diagnostic Studies and Interprofessional Care
01:26Guidelines for Nursing Documentation II
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
01:17Urinary Tract Infection IV: Nursing Management
01:06Legal Guidelines for Documentation
01:20Introduction to Documentation and Reporting
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive and precise...