Catheter Discharge Referral

Please select from the following before proceeding

Start new referral
Retrieve previous referral progress

Email Address

Reference Number

Verification Code (Please enter the code emailed to you)

Please complete this form, as fully as possible, with relevant information and details to support the referral.

Referrer Information

*Legal first name

*Legal surname

*E-Mail Address

*Department

*Telephone Number

*Is this referral for yourself?

Patient Details

*Legal first name

*Legal surname

*Date of Birth

*NHS Number

*Confirm catheter is safe to change in the community

*Patient's mobility level

*Do they require assistance?

*Care package information

Clinical indication

	Yes	No
*Haematuria - clots and heavy
*Urology / gynaecology / perianal surgery / prolonged surgery
*Decubitus ulcer - to assist the healing of a perianal/sacral wound in an incontinent patient
*Input / output - monitoring accurate < hourly or acute kidney injury when oliguric
*Nursing at the end of life
*Immobilisation - neurogenic bladder - unstable fracture or neurological impairment (where all other methods of toileting are contraindicated)
*Other

If you selected other - please give some more information

Obstruction / catheterised by a urologist (retention)

*Bladder scan amount: mL

	Yes	No	Unknown
*Is the patient / carer aware of the referral?
*Verbal Consent Given
*If unable to consent, MCA best interests completed
*Admitted with passport/existing catheter
*Patient advice leaflet given/information explained and given
*Discharged with catheter passport
*Confirmed latex allergy (if yes, use all silicone catheter)
*Confirmed chlorhexidine allergy

Insertion

*Date and time of insertion

*Name and role of person for catheter insertion decision:

	Yes	No
*Aseptic no touch technique used
*Urethral meatus/genital cleaned with normal saline pre-procedure
*Foreskin replaced (if applicable)

*Type of catheter:

*Reference Number (not LOT number, needed for prescriptions):

*Size:

*Supra pubic or Urethral

*Sterile anaesthetic lubrication used (brand and ml)

*Residual amount (ml)

*Balloon type/ml in balloon

*Type of catheter fixation device used ?

*Catheter valve or drainage bag used?

*Brand of catheter valve or drainage bag used

*Date catheter change is due

*Is the patient suitable for a trial without catheter (TWOC) in the community? If yes, or unknown, TWOC will be started in 2-3 weeks time.

*If the patient is not suitable for TWOC, please add information here on referral on to primary care to follow up. If not relevant please add n/a to text box.

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