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Fantl JA, Newman DK, Colling J. Urinary Incontinence in Adults: Acute and Chronic Management: 1996 Update. Rockville (MD): Agency for Health Care Policy and Research (AHCPR); 1996 Mar. (AHCPR Clinical Practice Guidelines, No. 2.)
This publication is provided for historical reference only and the information may be out of date.
Management of Urinary Incontinence in Primary Care
Sample Bladder Record
Sample Bladder Record
| NAME: | |||||
| DATE: | |||||
| INSTRUCTIONS: Place a check in the appropriate column next to the time you urinated in the toilet or when an incontinence episode occurred. Note the reason for the incontinence and describe your liquid intake (for example, coffee, water) and estimate the amount (for example, one cup). | |||||
| Time interval | Urinated in toilet | Had a small incontinence episode | Had a large incontinence episode | Reason for incontinence episode | Type/amount of liquid intake |
| 6-8 a.m. | |||||
| 8-10 a.m. | |||||
| 10-noon | |||||
| Noon-2 p.m. | |||||
| 2-4 p.m. | |||||
| 4-6 p.m. | |||||
| 6-8 p.m. | |||||
| 8-10 p.m. | |||||
| 10-midnight | |||||
| Overnight | |||||
| No. of pads used today: | No. of episodes: | ||||
| Comments: | |||||
Sample Incontinence Monitoring Record for Hospital and Nursing Home Patients
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