Digital Repository Masters Theses Spring 2026 Improving Urinary Tract Infection Symptom Documentation and Treatment Through Standardized Protocols in an Outpatient Urology Clinic Laura Lopez Weber State University Follow this and additional works at: https://dc.weber.edu/collection/wsudoctoral Lopez, L. 2026. Improving Urinary Tract Infection Symptom Documentation and Treatment Through Standardized Protocols in an Outpatient Urology Clinic. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/WSUDoctoral This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. WSU REPOSITORY MSN/DNP Improving Urinary Tract Infection Symptom Documentation and Treatment Through Standardized Protocols in an Outpatient Urology Clinic Project Title by Laura Lopez Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT 4/25/2026 Date Laura Lopez, BSN, RN, MSN Student 4/25/2026 Student Name, Credentials (electronic signature) Date Angela Page, DNP, APRN, PPNP-BC 4/25/26 MSN Project Faculty Date (electronic signature) 4/25/26 Anne Kendrick (electronic signature) DNP, RN, CNE MSN Program Director Note: The program director must submit this form and paper. Date 1 Improving Urinary Tract Infection Symptom Documentation and Treatment Through Standardized Protocols in an Outpatient Urology Clinic Laura Lopez Annie Taylor Dee School of Nursing Weber State University Angela Page, DNP, APRN, PPCNP-BC MSN Project April 13, 2026 2 Abstract Purposes/Aims: This project aims to improve the accuracy and consistency of urinary tract infection (UTI) symptom documentation and support appropriate treatment decisions in an outpatient urology clinic through staff education and standardized documentation protocols. Rationale/Background: The outpatient urology clinic frequently encounters patients with urinary symptoms that are not consistently documented, which can contribute to diagnostic uncertainty and variation in treatment decisions. Incomplete documentation can also lead to unnecessary antibiotic use and challenges in supporting clinical decision-making. Methods: A standardized documentation workflow and RN/MA checklist were developed to support consistent symptom documentation, along with a staff education session. Pre- and postimplementation surveys evaluated staff confidence and clarity regarding documentation expectations. Chart audits assessed documentation completeness before and after implementation. Lewin’s Change Theory guided the project, and confidentiality and voluntary participation were maintained. Results: Three key themes were identified with the standardized documentation workflow. The intervention 1) improves documentation consistency and completeness, 2) increases staff confidence in evaluating and documenting UTI symptoms, and 3) supports more appropriate antibiotic prescribing practices. Conclusions: By implementing standardized documentation and workflow support in an outpatient urology clinic, patient care can improve, antibiotic stewardship can be strengthened, and nursing practice can become more consistent. Keywords: urinary tract infection, documentation, outpatient nursing, antibiotic stewardship, quality improvement 3 Improving UTI Symptom Documentation and Treatment Through Standardized Protocols Urinary tract infections (UTIs) are among the most common bacterial conditions managed in healthcare, yet they pose challenges in outpatient practice. In many cases, diagnosis is limited by documentation that lacks standardized symptom details, which makes it difficult to distinguish between an actual infection and asymptomatic bacteriuria. Claeys et al. (2023) found that differences in how facilities document urinary symptoms contribute to variation in diagnosis and treatment. Inadequate charting also weakens antibiotic stewardship, as noted by Goebel et al. (2021), since missing or unclear details increase the likelihood of unnecessary prescriptions. This problem carries added weight in outpatient urology clinics, as many patients face recurring or complex urinary conditions that require thorough, consistent documentation to support accurate treatment and safe care. As a result, improving documentation becomes a key strategy that supports both accurate diagnosis and responsible antibiotic use. This quality improvement project aims to enhance the accuracy and consistency of urinary symptom documentation in the outpatient urology clinic by providing staff education and utilizing a standardized charting template, thereby strengthening antibiotic stewardship and improving patient outcomes. Statement of Problem In an outpatient urology clinic within a large academic medical center in Utah, it is concerning that UTI symptoms are not consistently documented by clinic nurses and medical assistants (personal communication, L. Lopez, October 2025). When records are incomplete, providers may struggle to distinguish between true infections and asymptomatic bacteriuria, which can delay or misdirect treatment. Claeys et al. (2023) reported that differences in documentation practices across facilities contribute to uneven diagnosis and management of UTIs. Gaps in documentation lower diagnostic accuracy and place patients at risk for less 4 reliable care. This aligns with findings from Yarrington et al. (2023), who emphasized that inadequate charting and communication among outpatient staff contribute to inconsistent care and higher error rates. The impact on antibiotic stewardship adds another layer to the problem. Goebel et al. (2021) found that poor charting contributes to unnecessary antibiotic use, undermining broader efforts to control resistance. Park et al. (2024) reported that providers often rely too heavily on patient-reported symptoms while underutilizing or under documenting laboratory data, thereby reducing the accuracy of clinical decisions. Stensgard et al. (2024) further demonstrated that asking clinicians to record their reasoning for urine culture orders reduced unnecessary testing, illustrating how structured documentation can enhance clinical judgment. Although documentation issues are common in many areas of healthcare, they carry particular weight in the outpatient urology clinic at a large academic medical center in Utah. Patients in this setting often have recurrent or complicated urinary problems that demand careful and consistent charting to guide treatment. When documentation is incomplete, providers may lack the necessary information to confirm an infection or to initiate appropriate treatment within 72 hours. This project aims to bridge that gap by introducing standardized documentation protocols and a triage checklist, supplemented with nurse education for outpatient clinic staff. The goal is to establish consistent practices that enhance diagnostic accuracy, minimize inappropriate antibiotic use, and improve overall patient outcomes. Nurses will gain clearer tools to support documentation, patients will benefit from safer, more timely care, and providers will have reliable records to inform evidence-based decisions, ultimately raising the standard of care in outpatient urology. Significance of the Project 5 Clear documentation of UTI symptoms by outpatient clinic nurses is essential because the details recorded in the chart directly shape diagnosis and treatment decisions. Claeys et al. (2023) demonstrated that variations in documentation practices among facilities contribute to inconsistent care and uneven patient outcomes. The problem carries particular weight in outpatient urology because patients frequently present with recurrent or complex urinary concerns. These cases require detailed, reliable records to guide safe and effective treatment. Establishing standardized documentation protocols helps reduce variation in practice by directing nurses to consistently record both symptom descriptions and laboratory findings, thereby supporting timely and accurate clinical decision-making (Goebel et al., 2021). İlhanlı et al. (2024) similarly found that structured nurse education on documentation improved compliance and accuracy across multiple ambulatory care settings, showing how training supports sustainable practice change. Another reason this project is essential is its connection to antibiotic stewardship. Goebel et al. (2021) noted that incomplete charting often leads to inappropriate prescribing, thereby weakening efforts to control resistance. Structured documentation has been shown to improve judgment and reduce unnecessary testing; for example, Stensgard et al. (2024) demonstrated that requiring providers to document the rationale for urine culture orders reduced unnecessary cultures. By introducing standardized documentation practices, this project aims to support more responsible use of antibiotics while strengthening overall stewardship in the outpatient setting. Finally, the project is significant because it enhances nursing practice and benefits multiple stakeholders. Park et al. (2024) noted that outpatient providers often rely heavily on patient descriptions of symptoms, while laboratory results are frequently underutilized or omitted from documentation. This pattern reduces the reliability of diagnostic decisions and creates care 6 inconsistencies. Standardized documentation protocols and focused nurse education address this problem by giving staff practical tools to guide assessment and record-keeping. The benefit is more apparent for patients: treatment decisions are based on a fuller picture of their condition. Nurses gain confidence and consistency in their practice, and managers have access to more accurate records that can be used to evaluate outcomes and guide improvement. In this way, the project advances patient safety, supports antibiotic stewardship, and reinforces the quality of care provided in outpatient urology. Review of the Literature This literature review examined current evidence on improving the accuracy and consistency of UTI documentation in outpatient urology settings. The goal was to identify strategies to address documentation gaps, promote appropriate antibiotic use, and enhance diagnostic accuracy. The PICOT question guiding this review was: For registered nurses caring for urology outpatients, does implementing standardized UTI outpatient lab and documentation protocols, compared to current practices, improve the accuracy of outpatient UTI symptom documentation, appropriate lab identification, and patient treatment within 72 hours of the encounter? The review identified several recurring themes across the evidence. Research consistently showed that structured documentation improves the quality and accuracy of charting while supporting better clinical decision-making. Stensgard et al. (2024) found that when providers documented the reason for ordering urine cultures, unnecessary testing decreased, and overall diagnostic accuracy improved. This evidence aligns with the project’s goal of improving documentation and supporting nurses through education to ensure consistent, high-quality care for patients in the outpatient urology clinic. 7 Framework Lewin’s Change Theory provides nurses with a straightforward approach to identifying areas for improvement and implementing lasting changes in their daily work. The model comprises three stages—unfreezing, change, and refreezing—that enable teams to recognize problems, try new approaches, and sustain successful ones. This framework aligns well with nursing projects focused on enhancing daily routines, as it fosters teamwork, open communication, and adaptability to change. Research by Flores et al. (2024) supports this idea, demonstrating that nurse-led quality improvement models encourage collaboration and improve adherence to standardized processes over time. These qualities enable new practices to become part of everyday work and remain consistent over time (Hojat et al., 2022). In this project, the unfreezing stage involves recognizing that when UTI symptoms are not clearly or completely documented, it can lead to incorrect diagnoses and unnecessary antibiotic use. The change stage introduces a new documentation template and nurse training to enhance charting accuracy and consistency. The refreezing stage focuses on maintaining those improvements by regularly reviewing charts and encouraging ongoing team feedback. Research indicates that clear, structured documentation can reduce unnecessary testing and improve patient outcomes (Stensgard et al., 2024). These steps help the changes become part of everyday practice and support accurate patient care decisions. Strengths and Limitations Lewin's Change Theory is well-suited for this project because it is straightforward to understand and can be easily applied in everyday nursing practice. The three stages — unfreezing, change, and refreezing — help teams navigate change in a clear, organized manner. One of the biggest strengths of this model is that it encourages staff involvement and 8 communication, which helps everyone understand why change is necessary and how to implement it effectively. This concept is also echoed by Dedeene et al. (2024), who found that engaging clinicians early in stewardship initiatives promotes long-term adoption and better consistency in documentation practices. Hojat et al. (2022) found that when nurses used clear, structured tools, their documentation and decision-making improved, which aligns well with this project's goal of creating more consistent UTI charting practices. One limitation of the model is that it can make change seem more straightforward than it really is. Because healthcare settings can be fast-paced and unpredictable, the steps of change may not always occur in a structured sequence. Stensgard et al. (2024) noted that maintaining new documentation habits requires ongoing support and leadership involvement, which the model does not always emphasize. Another challenge is that it takes time and consistent followup to make sure staff continue using the new process. To reduce these barriers, this project will include ongoing education and regular feedback from nurses and providers to sustain the new documentation process. Even with its limitations, Lewin's Change Theory offers a realistic framework for helping outpatient nurses enhance charting accuracy and improve patient care over time. Search Strategies To identify current evidence, a literature search was performed using the CINAHL, PubMed, Google Scholar, and Weber State University’s Stewart Library OneSearch databases. Only articles published from 2020 to 2025 were included to ensure up-todate research. The search included keywords such as “urinary tract infection” OR “UTI” AND “documentation” OR “charting” AND “antibiotic stewardship” OR “diagnostic stewardship” AND “nursing” OR “outpatient care.” Various Boolean combinations were used to capture 9 studies on standardized documentation, nurse-led education, and decision-support strategies. Results were limited to peer-reviewed articles focused on outpatient or ambulatory care settings and excluded commentaries and studies conducted in inpatient-only settings. Synthesis of the Literature The literature review revealed several patterns related to improving UTI documentation and antibiotic stewardship in outpatient care. Three main themes emerged: (a) the importance of standardized documentation to improve diagnostic accuracy, (b) the role of decision-support tools in strengthening antibiotic stewardship, and (c) the value of nurse-led protocols and implementation frameworks in sustaining long-term practice change. These themes suggest that integrating standardized documentation and nursing leadership leads to more accurate assessments, more appropriate antibiotic use, and improved care for urology patients. In the following sections, the literature is organized into three themes that reflect common findings across studies. Each theme brings together evidence from different studies showing the impact of standardized documentation, decision-support systems, and nursing-led interventions on UTI management in outpatient settings. The following review outlines the main trends found in the literature without personal interpretation. Standardized Documentation Improves Diagnostic Accuracy Several studies have demonstrated that structured documentation tools enhance the accuracy of UTI diagnosis and facilitate more consistent clinical decisions. Janine et al. (2024) observed that nurses were less likely to follow evidence-based guidelines when documentation systems lacked clear prompts, leading to incomplete or missing information. The authors noted that well-designed templates can guide nurses to include essential symptom details and laboratory findings for accurate assessment. In outpatient clinics, Whelan et al. 10 (2022) reported that unclear or incomplete urine culture documentation often contributed to contamination errors and unnecessary repeat testing. Clinics that used standardized forms had more accurate data and more dependable diagnostic outcomes. Other research supports these findings, showing that structured documentation contributes to higher-quality care. Mendoza De la Garza et al. (2024) found that nurses who followed a step-by-step diagnostic algorithm improved both the accuracy and timeliness of UTI identification in older adults. Decision-Support Tools Enhance Antibiotic Stewardship Several studies have demonstrated that the use of decision-support tools in clinical settings enhances diagnostic accuracy and reduces unnecessary antibiotic use (Hojat et al., 2022; Stensgard et al., 2024; Gilboa et al., 2024). Hojat et al. (2022) reviewed multiple studies and found that electronic decision-support systems helped providers apply evidence-based criteria when diagnosing UTIs, leading to more accurate treatment decisions and fewer unnecessary prescriptions. Similarly, Stensgard et al. (2024) implemented a CDSS menu within an electronic health record and found a statistically significant reduction in unnecessary urine culture orders. This intervention prompted providers to review diagnostic criteria before ordering tests, supporting antibiotic stewardship goals. The researchers found that real-time decision-support tools can influence provider behavior, reduce overtreatment, and improve resource utilization. Building on these findings, Gilboa et al. (2024) developed and validated an antimicrobial stewardship decision-support tool that assisted clinicians in differentiating between UTI and asymptomatic bacteriuria. The tool improved antibiotic selection and prescribing accuracy. Across multiple studies, integrating decision-support systems into daily workflows improved 11 evaluation consistency, reduced diagnostic errors, and supported antibiotic stewardship across different care settings. Nurse-Led Interventions and Education Recent studies have shown that nurse-led approaches and focused education improve the assessment and management of urinary tract infections in outpatient care. In one study, Mendoza De la Garza et al. (2024) created a nurse-led diagnostic algorithm for homebound older adults. Nurses who followed the outlined steps identified infections more accurately and acted more quickly. The results show that when nurses have clear guidance and practical tools, their assessments become more consistent and patient safety improves. Likewise, Karim et al. (2024) found that applying a nursing implementation framework helped nurses use evidence-based interventions more effectively. Those who followed a structured approach reported greater confidence and stronger adherence to best practices. These findings suggest that combining education with practical frameworks can increase the consistency and sustainability of documentation and diagnostic improvements. Nurse-focused interventions also align closely with broader quality and stewardship goals. By standardizing education and documentation tools, nurses can more effectively distinguish between true infections and asymptomatic bacteriuria, thereby reducing unnecessary testing and antibiotic use. Together, these studies show that when nurses receive training and use structured frameworks, documentation becomes more consistent, clinical decisions improve, and the overall quality of outpatient urology care increases. Summary of Literature Review Findings and Application to the Project Recent research has highlighted that the use of structured documentation tools, decisionsupport systems, and nurse-led education improves the identification and management of urinary 12 tract infections in outpatient care. Standardized templates make symptom charting more consistent and strengthen diagnostic accuracy. Decision-support tools help providers apply evidence-based guidelines when ordering urine tests or prescribing antibiotics, leading to more precise diagnoses and fewer unnecessary prescriptions. Nurse-led interventions and education also play a crucial role in enhancing assessment and documentation practices across various settings (Janine et al., 2024; Whelan et al., 2022; Mendoza De la Garza et al., 2024; Hojat et al., 2022; Stensgard et al., 2024; Gilboa et al., 2024). These findings strongly support this quality improvement (QI) project’s plan to implement a structured documentation template and targeted nurse education in the outpatient urology clinic. Applying these strategies can make symptom charting more accurate, reduce avoidable antibiotic use, and improve overall patient care. Combining nurse education with a straightforward documentation process empowers staff to consistently assess UTI symptoms and deliver care based on current evidence, thereby enhancing nurses' skills and confidence. Project Plan and Implementation The quality improvement project will be implemented in an outpatient urology clinic within a large academic medical center in Utah to improve the accuracy and consistency of UTI symptom documentation and support timely treatment decisions. The project will introduce a simple workflow-based documentation process supported by staff education and standardized tools. Education will be brief, lecture-style, and handout-based, and will include a Teaching Handout distributed to staff during the education session (see Appendix A). A role-based RN/MA Checklist will be used during patient encounters to guide documentation expectations and improve consistency (see Appendix B). Staff will also complete a pre-survey and post- 13 survey to evaluate confidence and perceived clarity of the workflow and documentation process (see Appendix C and Appendix D). Plan and Implementation Process This project will be implemented in an outpatient urology clinic where patients frequently present with recurrent urinary symptoms and complex histories. The project will focus on improving documentation processes and workflow consistency rather than changing provider prescribing authority or clinical treatment decisions. The affected populations include patients, medical assistants (MAs), registered nurses (RNs), urology providers, and clinic leadership/management. Before rollout, the project lead (MSN student RN) will meet with clinic leadership and key stakeholders to confirm how UTI symptom documentation currently occurs in the clinic and to finalize how the new workflow will fit into existing processes. During this planning phase, the project lead will finalize the deliverables that will support implementation, including the Teaching Handout for staff education (see Appendix A), the RN/MA Checklist (see Appendix B), and the staff pre- and post-surveys (see Appendix C and Appendix D). Education and training will be completed during a 1-hour staff meeting. The MSN student project lead will provide brief lecture-style education using a handout-based approach. The Teaching Handout will be distributed during the education session and will explain documentation expectations, the purpose of standardization, and what complete symptom documentation should include (see Appendix A). During the same session, staff will be introduced to the RN/MA Checklist and how it will be used during clinic encounters to guide consistent documentation and reduce missed symptom details (see Appendix B). 14 Following education, staff will complete a brief pre-survey to establish baseline perceptions of confidence and clarity related to UTI documentation and workflow expectations (see Appendix C). The pre-survey will use a single consistent response scale and be formatted for readability. The workflow will then be implemented in real-time clinic encounters when patients report or are evaluated for possible UTI symptoms. During these encounters, the MA role will support accurate intake documentation and ensure key baseline information is updated and communicated. The RN role will focus on clarifying symptoms and standardized documentation using checklist prompts. Providers will then review the improved documentation to guide testing, treatment decisions, and follow-up planning. Clinic leadership will support implementation by reinforcing expectations, answering workflow questions, and encouraging staff feedback during early adoption. A pilot period will last approximately 1–2 weeks to observe workflow effectiveness and identify barriers in real clinic flow. During the pilot period, staff will be encouraged to provide feedback on the checklist, workflow clarity, and any steps that feel unclear or difficult to complete consistently. Feedback will be collected using a shared/standard method, such as a simple shared document or designated feedback pathway, so that staff can report issues in real time. After the pilot period, the project lead will review common barriers and revise the workflow tools as needed to improve usability and consistency. The revised workflow and tools will then be implemented as the long-term process for documenting UTI symptoms in the clinic. From a patient-centered perspective, this workflow is expected to improve how the visit “feels” to patients by creating a consistent symptom assessment process and ensuring their concerns are captured clearly and thoroughly. From a clinic leadership perspective, the workflow diagram is intended to align staff responsibilities, visualize the whole process, and help identify 15 gaps or missed steps that can be improved over time. Ongoing evaluation will focus on whether the workflow improves documentation and supports clinic goals related to patient outcomes, including the long-term aim of reducing avoidable UTIs and improving appropriate treatment decisions. Interdisciplinary Team An interdisciplinary team is essential in healthcare to promote collaboration, improve communication, and ensure high-quality, patient-centered care. By bringing together individuals with diverse roles and expertise, interdisciplinary teams support more accurate clinical decisionmaking, reduce errors, and improve overall patient outcomes. Effective teamwork also helps standardize processes and ensure consistent patient care across the healthcare team. Description Interdisciplinary Team This project will require collaboration among outpatient urology clinic team members who contribute to symptom assessment, documentation, clinical decision-making, and sustainment of workflow expectations. The interdisciplinary team will include medical assistants, registered nurses, urology providers, and clinic leadership/management. Each team member will play a defined role in implementing and sustaining standardized documentation practices, and teamwork will support consistent care processes and improved patient outcomes. Registered Nurses (RNs). RN’s will be responsible for standardized symptom clarification and documentation during UTI-related encounters. RNs will use the RN/MA Checklist to guide consistent charting of symptom details and ensure documentation is complete enough to support provider interpretation. RNs will also reinforce a patient-centered approach by consistently and supportively asking symptom questions while clearly documenting the patient’s report in the medical record. 16 Medical Assistants (MAs). MAs will support implementation by completing intake steps during check-in and rooming and ensuring baseline documentation elements are accurate and up to date. MAs will document the patient’s chief concern and support workflow handoff by prompting or flagging the RN when symptom clarification is needed. The MA role supports workflow consistency by reducing missed intake details and improving communication across roles. Urology Providers (Physicians and Advanced Practice Providers). Urology Providers will use the improved symptom documentation to guide clinical decisions regarding testing, treatment, and follow-up. Providers will maintain authority over clinical decision-making while benefiting from more precise documentation that supports symptom interpretation and reduces uncertainty. Providers will also have an essential role in giving feedback on whether documentation elements meet clinical needs and whether workflow steps support timely and appropriate decision-making. Clinic Leadership and Management. Clinic leadership management will support implementation by approving the workflow-based approach, reinforcing expectations during staff meetings, and encouraging staff participation during the pilot and revision phase. Leadership support will be essential for sustainment by supporting staff questions and maintaining workflow consistency over time. Leadership will also help ensure feedback is welcomed and acted on, so the process can improve through real-world use. Description and Development of Project Deliverables Four deliverables will support the implementation of this quality improvement project. The deliverables include 1) a staff education handout that also serves as a unit flyer, 2) an RN/MA documentation checklist, 3) a pre-implementation survey, and 4) a post-implementation survey. Each deliverable was developed based on findings from the literature review supporting 17 standardized documentation, nurse-led education, and evaluation of practice change. This section describes each deliverable and its role in the project’s implementation. Staff Education Handout / Unit Flyer. The first deliverable is a staff education handout that also functions as a unit flyer (see Appendix A). This handout will be used during a staff meeting to introduce the project and outline standardized expectations for UTI symptom documentation. The handout includes key symptom elements that should be consistently documented, such as urinary urgency, frequency, dysuria, suprapubic pain, fever, and relevant laboratory findings. Short, focused educational materials have been shown to improve documentation consistency and reinforce evidence-based practice in outpatient settings (Janine et al., 2024; Karim et al., 2024). By combining education and visual reinforcement into a single deliverable, the handout supports staff understanding while minimizing disruption to clinic workflow. RN/MA Documentation Checklist. The second deliverable is an RN/MA documentation checklist (see Appendix B). This checklist was designed as a role-based tool to guide consistent symptom assessment and documentation during UTI-related encounters. The checklist provides structured prompts for medical assistants and registered nurses to ensure essential symptom information is clearly and thoroughly documented, including urinary urgency, frequency, dysuria, suprapubic pain, flank pain, hematuria, fever, and relevant laboratory findings. It will also prompt staff to document the type of urination (e.g., spontaneous voiding, clean intermittent catheterization (CIC), indwelling catheter, or suprapubic tube), as this information is critical for accurate assessment. Additionally, the checklist will reinforce that cloudy or foul-smelling urine alone, without other symptoms, is not sufficient to indicate a urinary tract infection. The literature supports the use of checklists and standardized templates to improve charting accuracy and reduce missed documentation elements (Mendoza De la Garza et al., 18 2024; Janine et al., 2024). During patient encounters, the checklist will serve as a cognitive aid that supports workflow consistency and diagnostic accuracy. Pre-Implementation Survey. The third deliverable is a pre-implementation survey (see Appendix C). This survey will be administered after staff education and before workflow implementation to assess baseline perceptions of confidence, clarity, and understanding regarding UTI documentation expectations. Pre-surveys are commonly used in quality improvement projects to establish baseline perceptions and guide interpretation of post-implementation results (Hojat et al., 2022). Results from this survey will help identify areas where additional clarification or support may be needed. Post-Implementation Survey. The fourth deliverable is a post-implementation survey (see Appendix D). This survey will be administered after the pilot implementation period to evaluate staff perceptions of the standardized documentation process. The survey will assess changes in confidence, clarity, and perceived usefulness of the documentation tools. Comparing pre- and post-survey responses will allow evaluation of the perceived impact of the project deliverables and inform decisions regarding sustainment and future refinement (Hojat et al., 2022). Timeline The proposed implementation timeline spans approximately 4 to 6 weeks (see Appendix E). During week one, the project lead will finalize deliverables and meet with clinic leadership to review implementation plans. In week two, staff education will occur, project materials will be distributed, and the pre-implementation survey will be administered. Weeks three and four will serve as the pilot implementation period, during which staff will use the standardized documentation tools during UTI-related encounters. Feedback will be 19 encouraged throughout this period. In week five, feedback will be reviewed, revisions made as needed, and the post-implementation survey administered. The standardized workflow will then be adopted as the ongoing documentation process. This project will implement standardized documentation tools and brief staff education to improve UTI symptom documentation in an outpatient urology clinic. Through structured deliverables, evaluation surveys, and a clear implementation timeline, the project aims to support consistent documentation practices, diagnostic accuracy, and antibiotic stewardship. Project Evaluation Project evaluation will determine whether the new documentation process improves consistency and increases staff confidence when documenting UTI symptoms in the outpatient urology clinic. This project will use both formative and summative evaluation methods to see whether the education and standardized documentation tools help improve practice and meet the overall project goals. Evaluation will take place before implementation, during the pilot phase, and after implementation to ensure the process is working and identify any areas that need improvement. Formative evaluation will occur during the implementation and pilot period. During the 1–2-week pilot phase, staff will be encouraged to share feedback on the RN/MA checklist and workflow. Feedback will be gathered through brief check-ins and a shared feedback method to identify any confusion and workflow challenges. This will allow minor changes to be made in a timely manner if something is unclear or complicated to follow. Informal observation of workflow use will also help determine whether staff are using the documentation tools as intended and whether additional support or clarification is needed. 20 Summative evaluation will occur after the implementation period to determine whether documentation consistency and staff confidence improve. A pre-implementation survey will be administered to staff after education and before the workflow begins to measure baseline confidence and clarity regarding UTI documentation expectations (see Appendix C). A postimplementation survey will then be distributed after the pilot period to evaluate whether staff feel more confident, whether the process is more transparent, and whether the documentation tools are helpful in daily practice (see Appendix D). Comparing the pre- and post-survey results will help determine whether the project improved staff confidence, clarity of documentation expectations, and perceived usefulness of the documentation tools in practice. A chart audit will also be completed before and after implementation to evaluate whether UTI symptom documentation becomes more consistent (see Appendix F). Charts will be reviewed for key symptoms, including dysuria, urgency, frequency, fever, suprapubic pain, flank pain, and hematuria, as well as relevant laboratory findings. Data will be collected from charts three months prior to implementation and three months following implementation of the standardized UTI documentation workflow. Permission to conduct the chart audit will be obtained from the Clinic Manager prior to data collection. No patient identifiers will be collected during this review. Improvement will be measured by comparing documentation completeness before and after implementation. Survey results, staff feedback, and chart audit findings will be reviewed with clinic leadership to determine project effectiveness and identify opportunities for continued improvement. Ethical Considerations This quality improvement project supports ethical and responsible practice by focusing on improving documentation accuracy, patient safety, and appropriate treatment within the 21 outpatient urology clinic. The project will be carried out respectfully and fairly, ensuring all staff receive the same education and access to documentation tools, so everyone is supported equally. The purpose of this project is to improve workflow and patient care rather than evaluate individual staff performance, and all team members will be supported equally throughout the process. Participation in surveys and feedback will be voluntary. Staff will be informed that survey responses will be used only to evaluate the effectiveness of the documentation process and education. Choosing not to participate will not affect staff roles, job evaluations, or working relationships within the clinic. Patient privacy and confidentiality will be protected throughout the project. Any chart audits will focus only on documentation completeness, and no patient identifiers will be collected. Survey responses will stay anonymous, and all information will be shared in a general, combined format to protect confidentiality. As the project lead and a member of the clinic team, I will remain aware of potential personal bias and will review all feedback and data objectively. To further support objectivity, chart audit findings and survey results will also be reviewed with an uninvolved clinic leader who is not directly participating in the project. Staff will be encouraged to share honest input so that the process can improve over time. The goal of this project is to support staff, strengthen documentation practices, and improve patient care while maintaining professionalism, respect, and confidentiality for everyone involved. Discussion This project will focus on improving how urinary tract infections are documented and evaluated in the outpatient setting by enhancing workflow support, staff education, and the consistent use of evidence-based practices. The goal will be not only to improve documentation, 22 but also to support clinical decision-making and antibiotic stewardship in a way that fits into everyday practice. This section will summarize dissemination of the project findings, their significance for nursing practice, anticipated strengths and limitations, and implications for future practice improvement. Evidence-Based Solutions for Dissemination The findings from this project will be shared both academically and within the clinical setting, including a poster presentation to faculty and fellow students during NRSG 6802, which will provide an opportunity to receive feedback and engage in scholarly discussion. In the clinical setting, dissemination will occur through structured communication with staff and clinic leadership. Education will continue with staff, the documentation checklist will remain available for use, and project results will be formally shared with clinic leadership to inform ongoing practice improvement efforts. The purpose of dissemination will be to ensure transparency of findings and promote shared understanding of the intervention outcomes. Following completion of the Plan-Do-Study-Act (PDSA) cycles, the sustainability of the practice change will be supported by integrating the standardized UTI documentation workflow into routine clinic processes. A written workflow guideline will be maintained, and clinic leadership will review documentation practices at designated intervals to monitor adherence and effectiveness. Ongoing review of documentation and regular feedback with staff will help the changes become part of everyday practice through continued PDSA cycles that support ongoing testing and refinement of practice changes (Institute for Healthcare Improvement [IHI], n.d.). Evidence-based and quality improvement literature supports the idea that improvement requires continued follow-up rather than a single intervention (Waldrop & Dunlap, 2024). The CDC also 23 notes that outpatient stewardship is strengthened when practice patterns are monitored, and clinicians receive ongoing support rather than relying on one-time education (CDC, 2025). Significance to the Advancement of Nursing Practice Urinary tract infections are a constant concern for nurses, especially in outpatient and urology care. Even though guidelines exist, practice can still vary depending on workload, workflow, and clinicians' confidence in applying those recommendations. Studies have shown that providers often face barriers, such as competing priorities and difficulty translating guidelines into day-to-day decisions (Park et al., 2024). Improving how UTIs are documented and how urine testing decisions are made has a direct impact on patient care. In practice, urine cultures are sometimes ordered without a clear indication or with important details missing, leading to unnecessary antibiotics or confusion about the patient’s clinical picture. Research on diagnostic stewardship shows that when teams use structured approaches and more transparent processes, testing becomes more appropriate and accurate (Claeys et al., 2023; Stensgard et al., 2024). Tools built into clinical workflows, like decision-support prompts, have also been shown to help clinicians pause and make more intentional choices about testing and treatment (Yarrington et al., 2023). National guidance reinforces the importance of this work. The CDC highlights outpatient stewardship as a priority and encourages health care teams to improve prescribing practices and track outcomes over time (CDC, 2025). The AUA/CUA/SUFU guideline also stresses the importance of evidence-based evaluation and management of recurrent urinary tract infections to avoid overtreatment and support appropriate care (American Urological Association et al., 2025). This project shows how small changes in everyday nursing work can make it easier to follow guideline-based care. When documentation is more precise, it helps paint a clearer picture 24 of what is happening with the patient and supports safer decision-making. Adjusting the workflow also helps nurses stay consistent with recommended practices without feeling like more is being added to their plate. Overall, these changes support more consistent, thoughtful, and evidence-informed care in the clinical setting. Implications A significant strength of this project is that it focused on realistic changes that could work in day-to-day practice. The documentation checklist and education were built around the current workflow, not on adding more steps or extra tasks. Because of that, the changes felt more doable and easier for staff to try. The project also followed the idea that practice changes should be based on both research and what is happening in the real clinical setting (Waldrop & Dunlap, 2024). There are still limitations to consider. Practice changes like this do not become routine “overnight”, and the interdisciplinary team members adjust at different speeds. Outpatient clinics are busy, making it hard to stay consistent. Staff turnover and shifting priorities can also affect how well new processes continue over time. Urine specimen collection is another ongoing challenge. Contamination remains common in outpatient settings and can affect results and treatment decisions, even as documentation improves (Whelan et al., 2022). Some of these issues are tied to patient factors and real clinical conditions that may not be fully controlled. Moving forward, these limitations highlight the need for continued support rather than a one-time change. Ongoing reminders, feedback, and leadership involvement will be important to help sustain improvements and support continued development. Recommendations 25 The next step is to focus on sustainability and ensure these changes continue over time. Monitoring documentation patterns, urine testing practices, and clinical decision-making will help determine whether the improvements remain consistent or begin to fade. Ongoing staff engagement will be important because practice changes often require reinforcement, follow-up, and leadership support to stay effective (Karim et al., 2024). There is also room to continue developing this work. Emerging decision-support tools and predictive models may help guide testing and treatment decisions, particularly in more complex cases (Dedeene et al., 2024; Flores et al., 2024; İlhanlı et al., 2024). Future research should also explore how these types of interventions perform across different outpatient settings and patient populations, since approaches that work well in one clinic may need adjustment in another. Integration of the documentation workflow into written clinic policy and designated staff responsibility will help ensure the process remains current and is updated as new evidence or recommendations emerge. Conclusions This project will identify gaps in documentation of urinary tract infections, urine testing practices, and stewardship support in an outpatient setting. The literature will show that unclear documentation and variation in testing influence how symptoms are interpreted and shape treatment decisions, including antibiotic use. It will also highlight the importance of diagnostic stewardship and the need for supports that align with both research evidence and real clinical workflows. These findings will point to the need for practical, sustainable changes that better support nurses and providers in everyday care. Implementation will center on staff education and the use of a documentation checklist, along with workflow adjustments that fit into existing clinic processes. The goal will be to 26 strengthen how information is captured, support more intentional testing decisions, and promote a more consistent approach to evaluating and managing UTIs. Because nurses play a central role in assessment and coordination of care in outpatient and urology settings, these changes will directly support their practice. Over time, this work will help the care team make clearer clinical decisions and support safer, more reliable care for the population served. 27 References American Urological Association, Canadian Urological Association, & Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. (2025). Recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU guideline (Amended 2025). https://www.auanet.org/guidelines-and-quality/guidelines Centers for Disease Control and Prevention. (2025). Core Elements of Outpatient Antibiotic Stewardship.https://www.cdc.gov/antibiotic-use/core-elements/outpatient.html Claeys, K. C., Weston, L. E., Pineles, L., Morgan, D. J., & Krein, S. L. (2023a). Implementing diagnostic stewardship to improve diagnosis of urinary tract infections across three medical centers: A qualitative assessment. 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Research in Gerontological Nursing, 17(2), 92–97. https://doi.org/10.3928/19404921-20240206-02 29 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/s12875-024-024773 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 Waldrop, J., & Dunlap, J. J. (2024). The mountain model for evidence-based practice quality improvement initiatives. AJN, American Journal of Nursing, 124(5), 32–37. https://doi.org/10.1097/01.naj.0001014540.57079.72 Whelan, P. S., Nelson, A., Kim, C. J., Tabib, C., Preminger, G. M., Turner, N. A., Lipkin, M., & Advani, S. D. (2022). Investigating risk factors for urine culture contamination in outpatient clinics: A new avenue for diagnostic stewardship. Antimicrobial Stewardship & Healthcare Epidemiology, 2(1). https://doi.org/10.1017/ash.2021.260 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 30 Appendix A Staff Education Handout / Unit Flyer 31 Appendix B RN/MA Documentation Checklist 32 Appendix C Pre-Implementation Survey 33 Appendix D Post-Implementation Survey 34 Appendix E Timeline 35 Appendix F Chart Audit