Continence Care Assessment and Documentation

Why Continence Documentation Matters

Incontinence affects over 50% of care home residents. Good continence care preserves dignity, prevents skin breakdown, and can identify underlying health issues. Proper documentation ensures consistent care, helps identify patterns, and provides evidence for CQC inspections.

Initial Continence Assessment

On admission, complete a thorough continence assessment covering:

Bladder and Bowel Charts

Accurate bladder and bowel charts help identify patterns and guide care planning:

Bladder Chart Records

• Time of each void or attempt
• Volume passed (if measuring)
• Whether continent or incontinent
• Prompted or self-initiated
• Urge level (1-10 scale if able to communicate)
• Any associated symptoms (pain, urgency, frequency)

Bowel Chart Records

• Date and time of bowel movement
• Bristol Stool Scale type (1-7)
• Amount (small, medium, large)
• Continent or incontinent
• Any straining or discomfort
• Presence of blood or mucus

Toileting Programme Documentation

For residents on a toileting programme, document:

• Scheduled times: When prompted toilet visits occur
• Response: Whether resident passed urine/stool
• Independence level: How much assistance needed
• Success rate: Track improvements over time
• Adjustments: Any changes to timing based on patterns

Continence Product Documentation

Record the continence products prescribed and their effectiveness:

• Product type, size, and absorbency level
• Times of scheduled changes
• Actual change times (day and night)
• Product condition at change (dry, damp, wet, soaked)
• Skin condition at each change
• Any issues with product fit or comfort

Skin Integrity Monitoring

Incontinence is a major risk factor for pressure injuries and dermatitis. Document:

Dignity in Documentation

Continence care is deeply personal. Documentation should:

• Use respectful, professional language
• Record resident's preferences (same-gender carer, specific routines)
• Note any distress and how it was addressed
• Document consent and involvement in care decisions
• Respect privacy in how and where records are kept

When to Escalate

Document and escalate to GP or continence service if:

• New or worsening incontinence
• Signs of urinary tract infection (cloudy, smelly urine, fever)
• Constipation not resolving with normal interventions
• Blood in urine or stool
• Significant skin breakdown
• Resident distress or request for specialist review

Care Plan Requirements

The continence care plan should include:

• Type and likely cause of incontinence
• Current management strategy (toileting programme, products)
• Products prescribed with sizes and change frequency
• Skin care regimen (barrier creams, cleansing products)
• Resident's preferences and level of involvement
• Signs of complications to watch for
• Review dates and specialist involvement