Male Urinary Catheterization Training Evaluation Form
Evaluate a learner’s performance in a male urinary catheterization training simulation using skills, safety, communication, and overall competency criteria.
Trainee and Session Information
Trainee Name
*
First Name
Last Name
Role / Training Level
*
Please Select
Medical Student
Nursing Student
Resident
Intern
Registered Nurse
Clinical Skills Trainee
Other
Evaluator Name
*
First Name
Last Name
Training Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Training Location / Department
Simulation / Scenario Type
*
Male Urinary Catheterization - Basic Technique
Male Urinary Catheterization - Sterile Setup
Male Urinary Catheterization - Difficult Insertion
Male Urinary Catheterization - Post-Procedure Care
Other
Evaluation of Catheterization Skills
Hand Hygiene
*
Rows
Not Demonstrated
Needs Improvement
Competent
Exceeds Expectations
Performs hand hygiene correctly before the procedure
1
2
3
4
Equipment Preparation
*
Rows
Not Demonstrated
Needs Improvement
Competent
Exceeds Expectations
Prepares and organizes all required catheterization equipment
5
6
7
8
Patient Identification
*
Rows
Not Demonstrated
Needs Improvement
Competent
Exceeds Expectations
Verifies the patient's identity using appropriate identifiers
9
10
11
12
Explanation and Privacy
*
Rows
Not Demonstrated
Needs Improvement
Competent
Exceeds Expectations
Explains the procedure clearly and maintains patient privacy and dignity
13
14
15
16
Aseptic Technique
*
Rows
Not Demonstrated
Needs Improvement
Competent
Exceeds Expectations
Maintains aseptic technique throughout the procedure
17
18
19
20
Genital Cleansing
*
Rows
Not Demonstrated
Needs Improvement
Competent
Exceeds Expectations
Performs genital cleansing using correct technique
21
22
23
24
Catheter Insertion Technique
*
Rows
Not Demonstrated
Needs Improvement
Competent
Exceeds Expectations
Inserts the catheter using correct technique and appropriate advancement
25
26
27
28
Urine Return Confirmation
*
Rows
Not Demonstrated
Needs Improvement
Competent
Exceeds Expectations
Confirms urine return before proceeding
29
30
31
32
Balloon Inflation Process
*
Rows
Not Demonstrated
Needs Improvement
Competent
Exceeds Expectations
Inflates the balloon correctly after confirming proper placement
33
34
35
36
Catheter Securement and Bag Placement
*
Rows
Not Demonstrated
Needs Improvement
Competent
Exceeds Expectations
Secures the catheter properly and positions the drainage bag appropriately
37
38
39
40
Documentation
*
Rows
Not Demonstrated
Needs Improvement
Competent
Exceeds Expectations
Documents the procedure accurately and completely
41
42
43
44
Post-Procedure Cleanup
*
Rows
Not Demonstrated
Needs Improvement
Competent
Exceeds Expectations
Performs post-procedure cleanup and disposal correctly
45
46
47
48
Clinical Judgment, Safety, and Communication
Complications Observed
*
None
Resistance during insertion
Patient discomfort
Bleeding
Inadequate sterile technique
Other
Remediation Needs
Overall Competency Decision
*
Competent
Competent with Remediation
Not Yet Competent
Evaluator Comments
Clinical Judgment, Safety, and Communication Ratings
*
Rows
Needs Improvement
Meets Expectations
Exceeds Expectations
Maintains patient safety
49
50
51
Recognizes resistance or complications
52
53
54
Responds appropriately to discomfort
55
56
57
Communicates clearly with the patient
58
59
60
Maintains professionalism
61
62
63
Follows facility protocol
64
65
66
Overall Performance Rating
*
1
2
3
4
5
Submit Evaluation
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