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Show Standardizing UTI Documentation in Urology BACKGROUND UTIs are common in outpatient care, but symptom documentation is often inconsistent.1 Incomplete charting makes it difficult to distinguish between true infection and asymptomatic bacteriuria, which can delay treatment or lead to unnecessary antibiotic use.2 This is especially important in outpatient urology, where patients often have complex or recurrent conditions.3 • • • • Inconsistent documentation affects diagnosis and treatment1 Missing details contribute to variation in care1 Poor documentation impacts antibiotic stewardship2 Standardization can improve accuracy and consistency4 Laura Lopez, BSN, RN, MSN Student Angela Page, DNP, APRN, PPCNP-BC Jane T. Kurtzman, MD INTERVENTIONS Step 1: Meet with clinic leadership to review current UTI documentation workflow Step 2: Develop and finalize project deliverables (education handout, RN/MA checklist, surveys) Step 3: Provide staff education during a 1-hour meeting Step 4: Distribute teaching handout and introduce RN/MA documentation checklist Step 5: Administer pre-implementation survey to assess baseline confidence and clarity Step 6: Implement standardized documentation workflow during UTI-related encounters Step 7: Conduct a 1–2 week pilot period and collect staff feedback Step 8: Revise workflow and tools based on feedback Step 9: Administer post-implementation survey to evaluate impact Step 10: Continue workflow as standard practice and monitor documentation through chart audits5 IMPACTS The project is expected to improve documentation practices and support better clinical decision-making.5 METHODS This quality improvement project will be implemented in an outpatient urology clinic in a large academic medical center in Utah. The goal is to improve documentation accuracy and workflow consistency using education and standardized tools. • Improved documentation consistency and completeness1 • Increased staff confidence and clarity5 • Better support for provider decision-making5 • Strengthened antibiotic stewardship2 • More consistent outpatient care1 • Improved patient safety and treatment timeliness3 • Framework: Lewin’s Change Theory • Staff education session (1-hour) • Teaching handout developed • RN/MA documentation checklist created • Pre- and post-surveys to assess confidence and clarity5 • Chart audits before and after implementation • 1–2 week pilot period with staff feedback FreeImages(2026)6 CONCLUSIONS Standardized documentation and staff education can improve the recording and evaluation of UTI symptoms in outpatient urology.1,5 Clear and consistent charting supports accurate diagnosis, appropriate treatment, and improved patient care.1,2 REFERENCES • • • • 1 Claeys, K. C., Weston, L. E., Pineles, L., Morgan, D. J., & Krein, S. L. (2023). Implementing diagnostic stewardship to improve diagnosis of urinary tract infections across three medical centers: A qualitative assessment. Infection Control & Hospital Epidemiology, 44(12), 1932–1941. https://doi.org/10.1017/ice.2023.106 2 Goebel, M. C., Trautner, B. W., & Grigoryan, L. (2021). The five DS of outpatient antibiotic stewardship for urinary tract infections. Clinical Microbiology Reviews, 34(4). https://doi.org/10.1128/cmr.00003-20 3 Park, J., Torosis, M., Kim, J.-H., & Ackerman, A. L. (2024). U.S. primary care physician perceptions on barriers to providing guideline-driven care for UTI and recurrent UTI: A qualitative study. BMC Primary Care, 25(1). https://doi.org/10.1186/s12875024-02477-3 4 Stensgard, E., Masoud, B., Gravely, A., & Drekonja, D. (2024). Clinical decision support menu for reducing unnecessary urine cultures. Antimicrobial Stewardship & Healthcare Epidemiology, 4(1). https://doi.org/10.1017/ash.2024.47 5 Yarrington, M. E., Reynolds, S. S., Dunkerson, T., McClellan, F., Polage, C. R., Moehring, R. W., Smith, B. A., Seidelman, J. L., Lewis, S. S., & Advani, S. D. (2023). Using clinical decision support to improve urine testing and antibiotic utilization. Infection Control & Hospital Epidemiology, 44(10), 1582–1586. https://doi.org/10.1017/ice.2023.30 6 FreeImages. (2026). Image of kidneys [Photograph]. https://www.freeimages.com 7 FreeImages. (2026). Nurses communicating [Photograph]. https://www.freeimages.com FreeImages(2026)7 Supports accurate clinical decision-making Improves consistency in nursing practice Enhances workflow and communication Promotes safer, evidence-based care |
