Name: Hematuria — bulletproof documentation — ER Toolkit
Creator: Kim Trinh, MD

Two moves make the hematuria chart defensible: confirm it's really blood (microscopy, not the dipstick), and decide whether the source is glomerular or urologic. In adults, painless gross hematuria is a urinary-tract cancer until proven otherwise — and the dominant medicolegal exposure is the missed malignancy referral.

01What's at stake

A dipstick positive for blood can be myoglobin, hemoglobin, menstrual contamination, a food, or a drug — so a microscopy-confirmed red cell is the first defensible step. From there, dysmorphic cells and red-cell casts point to the kidney (glomerulonephritis, HUS), while clots and a normal red-cell morphology point to the urologic tract (stone, infection, trauma, tumor). The adult with painless gross hematuria needs a urology referral even when the ED workup is "normal."

02Can't-miss causes

Genitourinary malignancy (adults) — painless gross hematuria is bladder/renal cancer until proven otherwise → urology referral for cystoscopy/imaging. → urology referral
Clot retention — clots obstructing the bladder → large-bore catheter, irrigation. → restore voiding
Glomerular disease — glomerulonephritis (post-strep, IgA, HSP) and HUS (hematuria + pallor/anemia + thrombocytopenia + AKI); check BP and renal function.
Obstructing infected stone — flank pain, fever, hydronephrosis → decompression emergency.
Trauma — gross hematuria after blunt injury → CT.

03Workup

Confirm true hematuria — every dipstick positive for blood gets microscopy; RBC-negative means myoglobin/hemoglobin/menstrual/food/drug. → confirm on micro
Glomerular vs urologic — dysmorphic RBCs/RBC casts/proteinuria/cola urine (glomerular) vs clots/bright-red/normal morphology/pyuria (urologic).
Blood pressure and renal function; CBC/coags as indicated; urine culture if infection suspected.
Imaging by suspicion — ultrasound first-line for stones/obstruction; CT for gross hematuria after blunt trauma. → confirm voiding in clot retention

Skip the typing

Work the case in the Hematuria Workup — it records confirmation of voiding/clot status and the urology referral, and assembles an MDM that documents the malignancy and dangerous causes were addressed.

04Management

Clot retention: three-way catheter, manual evacuation, continuous bladder irrigation; urology for ongoing bleeding and source workup.
Glomerular/HUS/renal failure/severe HTN: nephrology, careful BP control (lower by no more than ~25% over 6 h), and admission for the acutely ill.
Obstructing infected stone: urgent urology for decompression plus antibiotics.
Stable, confirmed hematuria: close follow-up — even intermittent/asymptomatic hematuria can signal progressive disease; adult unexplained hematuria → urology referral for malignancy evaluation.

05What to document

▼ weak

"Urine dip positive for blood. UTI, antibiotics, discharged."

▲ defensible

"62-year-old smoker with painless gross hematuria. Dipstick blood confirmed on microscopy (RBCs present — not myoglobin/hemoglobin); no menstrual source, no recent foods/drugs. Normal RBC morphology, no casts or proteinuria (non-glomerular); BP normal, creatinine normal, no clots/retention (voiding confirmed). No infection (no pyuria/symptoms). Given painless gross hematuria in an adult smoker → urology referral for cystoscopy and upper-tract imaging (malignancy workup) explicitly arranged. Return precautions for clots/inability to void, fever, flank pain, or large-volume bleeding."

06Where charts fail

Calling a dipstick "hematuria" without microscopy (missing myoglobin/hemoglobin).
Not referring an adult with unexplained/painless gross hematuria for malignancy workup.
Missing the glomerular picture (RBC casts, hypertension, proteinuria) or HUS (pallor + thrombocytopenia + AKI).
Missing clot retention or an obstructing infected stone.
No blood pressure, no follow-up — a negative ED UA does not exclude progressive disease.

07Sources

Kim S, Liu DR, Pade KH. Emergency department management of hematuria in children: an updated, evidence-based approach. Pediatric Emergency Medicine Practice (EB Medicine). 2025;22(6).
Barocas DA, Boorjian SA, Alvarez RD, et al. Microhematuria: AUA/SUFU guideline. J Urol. 2020;204(4):778-786.
Brown DD, Reidy KJ. Approach to the child with hematuria. Pediatr Clin North Am. 2019;66(1):15-30.
Davis R, Jones JS, Barocas DA, et al. Diagnosis, evaluation and follow-up of asymptomatic microhematuria in adults: AUA guideline. J Urol. 2012;188(6 Suppl):2473-2481.

Hematuria: documentation that holds up