= YES = NO ✓ ✗

(PLACE PATIENT LABEL HERE)

SURNAME: ____________________________________ NHI: _____________

FIRST NAMES: ____________________________________________________

Date of Birth: _______ /_______ /_______ SEX: _____________

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URINARY SYMPTOMS IN ADULTS(Suspected Urinary Tract Infect ion - UTI)

Date: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMODate: / / 20 Time: Clinician: NP CNS HS Reg SMO

HISTORY, PRESENTING COMPLAINT & SYSTEMS REVIEWHISTORY, PRESENTING COMPLAINT & SYSTEMS REVIEWHISTORY, PRESENTING COMPLAINT & SYSTEMS REVIEWHISTORY, PRESENTING COMPLAINT & SYSTEMS REVIEWHISTORY, PRESENTING COMPLAINT & SYSTEMS REVIEWHISTORY, PRESENTING COMPLAINT & SYSTEMS REVIEWHISTORY, PRESENTING COMPLAINT & SYSTEMS REVIEWHISTORY, PRESENTING COMPLAINT & SYSTEMS REVIEWUnwell for : Unwell for : Unwell for : Unwell for : Unwell for :

GU: Dysuria Frequency Supra-pubic pain Supra-pubic pain Haematuria

Gen: Fever / rigors Nausea / vomiting Nausea / vomiting Flank / back pain Flank / back pain

GI: Abdominal painSTI risk Sexually active

Previous STI PV / penile discharge PV / penile discharge

Prostatitis Rectal / perineal pain pain Rectal / perineal pain pain

RELEVANT MEDICAL & SURGICAL HISTORY RELEVANT MEDICAL & SURGICAL HISTORY RELEVANT MEDICAL & SURGICAL HISTORY RELEVANT MEDICAL & SURGICAL HISTORY RELEVANT MEDICAL & SURGICAL HISTORY Nil relevant Nil relevant Nil relevant Immunosupression Immunosupression Pregnant Pregnant IDDM / NIDDM IDDM / NIDDM Previous UTI / urosepsis Previous UTI / urosepsis IDUC / instrumentation IDUC / instrumentation

RELEVANT MEDICATIONS / ALLERGIES RELEVANT MEDICATIONS / ALLERGIES RELEVANT MEDICATIONS / ALLERGIES RELEVANT MEDICATIONS / ALLERGIES RELEVANT MEDICATIONS / ALLERGIES Nil regular Nil regular Nil regular

Nil known allergies Nil known allergies ALLERGIES:FUNCTIONAL & SOCIAL HISTORY FUNCTIONAL & SOCIAL HISTORY FUNCTIONAL & SOCIAL HISTORY FUNCTIONAL & SOCIAL HISTORY FUNCTIONAL & SOCIAL HISTORY Nil relevant Nil relevant Nil relevant

ADL Independent Smoking Non smoker Smoker:

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(PLACE PATIENT LABEL HERE)

SURNAME: ____________________________________ NHI: _____________

FIRST NAMES: ____________________________________________________

Date of Birth: _______ /_______ /_______ SEX: _____________

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EXAMINATIONEXAMINATIONEXAMINATIONEXAMINATION

CVS Warm and well perfused Warm and well perfused

Cap refill Normal

Pulses Normal

Respiratory

Breathing work Normal

Breath sounds Vesicular

Abdominal

Appearance Not distended Distended

Palpation Soft Tender

Guarding No Yes:

Rebound tender No Yes:

Renal angle tender No Yes:

Organomegaly None

Bowel sounds Normal

♀ Vaginal examination Look for signs of infection♀ Vaginal examination Look for signs of infection♀ Vaginal examination Look for signs of infection♀ Vaginal examination Look for signs of infection Not indicated

Indications: PV discharge or unilateral abdominal painIndications: PV discharge or unilateral abdominal painIndications: PV discharge or unilateral abdominal pain Performed by: Dr _______________________________Performed by: Dr _______________________________Urinary meatus Normal Discharge Lesions: describe:

Cervix Normal Motion tender Swabs sent x 3

Adnexae Not tender TenderPalpable mass No Yes:

♂ Genital examination: Always rule out STI in all sexually active men♂ Genital examination: Always rule out STI in all sexually active men♂ Genital examination: Always rule out STI in all sexually active men♂ Genital examination: Always rule out STI in all sexually active men Not indicated

Indications: PV discharge or unilateral abdominal painIndications: PV discharge or unilateral abdominal painIndications: PV discharge or unilateral abdominal pain Performed by: Dr _______________________________Performed by: Dr _______________________________External genitalia Normal Discharge Swabs sent Swabs sent

Lesions:

Testes Normal

Prostate Normal Tender Irregular

VITAL SIGNS

Within normal limits

VITAL SIGNS

Within normal limits

BP ______________ mmHgBP ______________ mmHg Resp Rate _________ minResp Rate _________ min Pain score _____ /10Pain score _____ /10VITAL SIGNS

Within normal limits

VITAL SIGNS

Within normal limitsPulse ______________ bpmPulse ______________ bpm SPO2 ______________ %SPO2 ______________ %

VITAL SIGNS

Within normal limits

VITAL SIGNS

Within normal limitsTemp ______________ ℃Temp ______________ ℃ Air NP Hudson: ____ l/min Air NP Hudson: ____ l/min Air NP Hudson: ____ l/min Air NP Hudson: ____ l/min

General NOT distressed

Pain None Mild Moderate Severe

Dehydration None Mild Moderate Severe

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RESULTS RESULTS RESULTS RESULTS RESULTS RESULTS RESULTS RESULTS RESULTS RESULTS RESULTS RESULTS HAEMATOLOGYHAEMATOLOGY BIOCHEMISTRYBIOCHEMISTRYBIOCHEMISTRYBIOCHEMISTRYBIOCHEMISTRYBIOCHEMISTRY URINE: DipstixURINE: Dipstix MSU / CSUMSU / CSU

Hb Na+ CRP Leuc Est WCC

PL K+ β-HCG Nitrites RCC

WCC Gluc Prot Epi’s

Creat Bact

Lipase

Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair Remember to note Antibiotics given in the comments box in Eclair

PREVIOUS URINE CULTURESPREVIOUS URINE CULTURES Not applicableDate:

Bacteria:

Sensitivities:

Resistance:

SWAB RESULTS Not applicable

Site(s):Site(s):Site(s):Site(s):Site(s):

OTHEROTHEROTHEROTHER

= YES = NO ✓ ✗

(PLACE PATIENT LABEL HERE)

SURNAME: ____________________________________ NHI: _____________

FIRST NAMES: ____________________________________________________

Date of Birth: _______ /_______ /_______ SEX: _____________

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Clinician Name: Designation: Sign: Contact details: _________

For junior staff: Discussed with Reviewed by SMO Dr : _____________________ Sign: __________

CLINICAL IMPRESSION CLINICAL IMPRESSION CLINICAL IMPRESSION CLINICAL IMPRESSION CLINICAL IMPRESSION Diagnosis Uncomplicated UTI Uncomplicated UTI DDx includes:

See definitions page 3

Best Care Bundle Pathway

Pyelonephritis Upper UTI Pyelonephritis Upper UTI See definitions

page 3 Best Care Bundle

Pathway

Urosepsis UrosepsisSee definitions

page 3 Best Care Bundle

Pathway Catheter associated UTI Catheter associated UTI

See definitions page 3

Best Care Bundle Pathway

Other: Other:

PLAN / NURSING INSTRUCTIONSPLAN / NURSING INSTRUCTIONSPLAN / NURSING INSTRUCTIONSPLAN / NURSING INSTRUCTIONSPLAN / NURSING INSTRUCTIONS

Antibiotics WDHB antibiotic guidelines page 4 Best Care Bundle PathwayWDHB antibiotic guidelines page 4 Best Care Bundle Pathway

Analgesia

IV fluids

Disposition Discharge EDS proforma (link from EDS) already pre-populated with patient informationEDS proforma (link from EDS) already pre-populated with patient informationEDS proforma (link from EDS) already pre-populated with patient information

Inpatient admission: D/W Dr: _________________ Specialty: _____________ Time: _______ Inpatient admission: D/W Dr: _________________ Specialty: _____________ Time: _______ Inpatient admission: D/W Dr: _________________ Specialty: _____________ Time: _______ Inpatient admission: D/W Dr: _________________ Specialty: _____________ Time: _______

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