Documentation Guidelines

• Description of all dressings, wounds, drainage collection devices, and urinary output; location, color, and amount of drainage; appearance of incision; color and amount of urine; presence of clots in the urine; urinary pattern after catheter removal

• Physical findings related to the pulmonary assessment, abdominal assessment, presence of edema, condition of extremities, bowel patterns, presence of complications (hemorrhage, infection, pulmonary congestion, activity intolerance, unrelieved discomfort, blockage of Foley catheter)

• Urinary pattern following removal of Foley catheter

• Response to potential for alteration in sexual function

• Description of the skin in the radiation field or site of insertion of radiation implant

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