Patient Bladder Chart
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1
2BLADDER CHART/DIARY
Duke Urology of Raleigh
PATIENT INSTRUCTIONS
Patient Name:________________________________
1. Enter the time of every void (bladder emptying). Use any container with marked volumes (i.e. measuring cup,
urinary hat, etc.), measure and record the volume of each void. Record the time you go to bed and the time
you arise in the morning for each day’s voiding entries.
2. Note any episodes of wetting or loss of bladder control by placing a
mark at the time the episode occurred.
3. Note if leakage resulted in a mild (drops), moderate (pad or underwear feels damp), or large amount (pad or
underwear saturated) of wetness.
4. Describe what activity, if any, you were doing when the incontinence occurred.
5. The bladder chart should be maintained for at least three consecutive days and nights.
6. All information will be kept confidential and used only for clinical purposes. If you have any questions please
call 684-5299.
Example of Bladder Diary/Chart:
AM Rise
& PM Retire
Times
DAY
TIME
VOLUME
WETTING
Amount of leakage
Activity performed when leaked
6:00 AM
11/1/02
6:00 AM
400 cc
mild
going to bathroom
8:00 AM
200 cc
9:00 AM
50 cc
12:00 PM
150 cc
1:00 PM
200 cc
4:00 PM
large
cough
9:00 PM
moderate
washing dishes
10:30 PM
10:30 PM
200 cc
12:00 AM
100 cc
mild
going to bathroom
7:00 AM
11/2/2002
7:00 AM
350 cc
mild
going to bathroom
9:30 AM
200 cc
12:00 PM
100 cc
2:30 PM
150 cc
large
cough/sneeze
5:30 PM
200 cc
8:30 PM
150 cc
mild
cough
10:00 PM
10:00 PM
200 cc
AM Rise
& PM Retire
DAY
TIME
VOLUME WETTING Amount of leakage
Times
Activity performed when leaked
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