Chapter 66 · Practical algorithms
Quality assurance and documentation in emergency urological care
General principles
Medical documentation must support continuity of care, demonstrate timely completion of key actions, and allow the reasoning behind decisions to be reconstructed. Make entries immediately after assessment or intervention and update them whenever the patient's condition changes.
Required information in the initial record
- date and time of arrival, triage, initial assessment, and reassessments;
- presenting symptoms, circumstances and time of symptom onset, comorbidities, surgery, and procedures;
- allergies, medication history, anticoagulant and antiplatelet use, pregnancy, and immune status;
- vital signs, illness severity, examination findings, and investigation results;
- working diagnosis, differential diagnosis, identified risks, and rationale for the chosen management;
- monitoring plan, escalation criteria, and responsible specialist.
Critical timestamps
- time of referral to and assessment by the urologist, anesthesiologist/intensivist, and other specialists;
- time of microbiological sampling, initiation of drug therapy, and receipt of results;
- time imaging was requested and performed;
- time the decision to intervene was made, and the start and completion of the procedure;
- time transfer was agreed and the patient's transfer actually began.
Documenting the procedure and inserted device
| Section | Information to record |
|---|---|
| Before the procedure | Indication, patient identification, side and level of intervention, consent or grounds for emergency treatment, allergies, hemostatic status, and availability of required equipment. |
| Procedure details | Date and time, operator and participants, method of analgesia/anesthesia, number and nature of attempts, instruments and materials used, samples obtained, and technical outcome. |
| Complications | Complications or their absence, measures taken, consultations, and monitoring plan. |
| Device | Type, size/model if available, side, insertion date and time, fixation, patency, volume and nature of output, date for review, replacement, or removal, and responsible person. |
| After the procedure | Patient condition, monitoring, restrictions, orders, reassessment criteria, and the next stage of treatment. |
Handover and discharge
- use a structured handover on transfer, covering clinical status, actions taken, devices, complications, and outstanding tasks;
- at discharge, provide clear advice on follow-up, device care, signs of deterioration, review timing, and where to seek further care;
- assign responsibility for reviewing pending culture, histology, imaging, and other investigation results and contacting the patient;
- document refusal of care, impaired decision-making capacity, involvement of a legal representative, and grounds for emergency intervention according to the established procedure.
Quality assurance
| Indicator group | Examples |
|---|---|
| Process | Timeliness of assessment, consultation, diagnosis, intervention, and transfer; completeness of handover. |
| Outcome | Complications, reattendance, unplanned repeat interventions, ICU transfer, length of stay. |
| Device safety | Proportion of devices with a documented review/removal date; unplanned occlusion, migration, or infection; completeness of the register. |
| Medication safety | Documentation of allergies, kidney function, anticoagulants, and treatment adjustment based on investigation results and the local formulary. |
| Documentation | Presence of critical timestamps, consent/refusal, procedure record, follow-up plan, and instructions on deterioration and seeking further care. |
Clinical audit: address identified systemic problems through a corrective action with a named responsible person, deadline, outcome verification, and, where necessary, revision of the local referral pathway or guide.
Informed consent and emergency intervention
- Before an invasive procedure, obtain informed consent from the patient or legal representative and document the purpose, main risks, alternatives, and consequences of refusal.
- When there is an immediate threat to life or risk of serious harm, the patient cannot express their wishes, and a legal representative is unavailable, provide care without consent only on the grounds specified in the Code of the Republic of Kazakhstan.
- Record the circumstances preventing consent, urgency, those involved in the decision, the intervention performed, and subsequent communication with the patient or representative.
- Document refusal of care by the patient or legal representative. When a child's life or that of a patient lacking legal capacity is threatened, follow the procedure established by law without unjustifiably delaying emergency care.
Regulatory basis: KZ-02, KZ-04, KZ-05, KZ-07, KZ-10, KZ-11, KZ-12, KZ-13, and KZ-14. Forms and checklists are provided in Appendices 4 and 5.