Table 1

Scoring criteria for clinical documentation

Scoring dimensions for information in UTI charts and templates
 General dataSex (non-pregnant patients only)Documented on first pageCircle filled
Visit information
(First/Follow-up/ANC visit)
Documented in encounterCircle filled
Pregnancy details—trimesterDocumented in encounterCircle filled
Pregnancy details—gravidity, ParityDocumented in encounterCircle filled
 AssessmentUTI type (lower/upper/complicated UTI)Clear documentation of subdiagnosisAny subdiagnosis filled
Possible associated STIDocumentation of STI symptoms
(positive or negative)
Circle filled
 TestingUrine dipstick/microscopyTest mentioned in encounterCircle filled
Urine cultureTest mentioned in encounterCircle filled
 ManagementPrescription/Management instructionsClear management orders in encounterAny management circles filled
Hydration instructionsNoted in encounter as management or counsellingCircle filled in either management or counselling
Treatment durationTreatment duration clearly documentedCircle filled
CounsellingAny counselling (eg, antibiotic use, risk factors, hygiene) documentedAny counselling circles filled
 # Criteria10 (11 in pregnant women)
Control dimensions (information documented outside templates)
 General dataPresenting complaintsNoted in encounterN/A
 Vital signsBlood pressureExact values documentedN/A
Heart rateN/A
 Follow-upFollow-up instructionsFollow-up date documentedN/A
 # Criteria6
  • ANC, antenatal care; STI, sexually transmitted infection; UTI, urinary tract infection.