Dialysis Treatment Record [PDF]

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HEMODIALYSIS TREATMENT RECORD Date



D



D



M



M



M



Y



Y



Y



Advance Care Plan



Y



Allergies Isolation Precautions HD Unit



Inpatient



Assigned Nurse(s)



UNIT



HD Start Time



24 HOUR



INITIALS



Estimated End Time 24 HOUR



HD Off Time



INITIALS



24 HOUR



INITIALS



Outpatient Last Order Date



HD Chart Orders



D



D



M



M



M



Y



Y



Y



Last 3 Tx Records



Y



Appt. Reminders



K+



Ca++



DELIVERY SYSTEM



UF Time



ISO UF



Stn #



Gluc



HCO3



Chem. residue



Prescribed Na+



T1



Flow



Temperature



Na+ Profile



Start Na+



Dialysate Shunt Door Flow Ven. Line in Clamp



UFC



Critical RBV%



Max UFR



V (urea)



Goal Kt/V



ACCCESS



R



Instillation:



LABS: pre HD:



Yes Bolus/Prime Rate Stop Time



Yes



post HD:



No



BG: pre HD: units units/hour Flushes: minutes Cont. 0.9% NaCl:



Site Care/Assessment



L Site



Dressing Change:



Level Set



HEPARIN



Comments



CVC:



Other:



Machine #



Dialysate #



UF profile #



MEDICATIONS/TRANSFUSIONS



N/A Antibiotics:



DIALYSIS PRESCRIPTION/PARAMETERS Dialyzer



Yes



mid: Yes Yes



AVF



No No



Frequency q Volume



Heparin 1000 units/mL



AVG



R



L



Yes



No



# Punc.



Needle Type: Lidocaine:



Arterial



mL



Venous



mL



Remove Post HD Dressing at



NURSING ASSESSMENT AND PLAN WBC



HgB



Plt



K+



min



Site



No



Other:



Date



post HD:



Urea



Ca++



PO4



Alb



24 HOUR



FLUID MANAGEMENT PTH



Other



DRY WEIGHT PRE HD WEIGHT



CNS: LOC Pain Headache CVS: Chest Pain Bleeding Weakness Resp: Cough/Sputum SOB GI/GU: Appetite N+V BM Wound/Skin Care Due: Yes No Pt. Achieves Goal Kt/V: Pre HD: B/P SIT: STAND: P: Other/Additional Information: See IPN Inpatient:



Dizziness Fever/Chills Lung Sounds



Cramping Edema



Dysuria Yes No Pt. Achieves Assigned DW: Yes T: RR: Ward Chart Orders Reviewed Initials:



TARGET WEIGHT Weight Difference No



PO Intake IV Intake Flushes/Infusion Reinfusion Volume Subtotal



Nursing Dx/Plan:



Replacement Fluid



Total UF Goal Notify:



RD



Pharm



SW



OT



Other Initials:



NEXT TREATMENT REMINDERS:



FORM # W-00497



01/18



Initials (calculations) POST WEIGHT



COPY TO BE RETAINED IN HSC RECORD - FLOW SHEETS (YELLOW)



Page 1 of 2



Transfer of Care/Report: 24 HOUR



Time Time Time



Received by Received by Received by



Postchecks:



Initial Isolation Room Alarm Connected ������ Dialysate Flow at Prescribed Rate ����� Hemodialert ���������������������������������������� Heparin Line Open/On ������������������������ TIME



B/P



HR



Qb



Initials Initials Initials Yes Yes Yes Yes



N/A N/A N/A N/A



AP/VP



Na+ Profile Set ���� Yes N/A UF Profile Set ������ Yes N/A UF Timer On ������ Yes UF Goal Set ������������������ mL UFR



UF REM’D



RBV



Heparin In



Date Clearance



D



Kt/V



D



M



M



M



Y



Y



Y



LINES SECURE



Y



COMMENTS Heparin Bolus given



TREATMENT REMINDERS



Yes



INITIAL N/A



POST HEMODIALYSIS HD Tx Outcome: Net Fluid Removed: Vital Signs Time B/P Sit:



FLUSHES TIME



VOLUME



See IPN



24 HOUR



COMMENTS



mL Post HD Weight: B/P Stand: Pulse: T: RR:



INITIALS



INITIAL



Meets Discharge Criteria Time of Discharge Discharged:



Yes 24 HOUR



Home



Transfer of Care/Report:



kg Final Kt/V:



No ���������������������������



Initials



��������������������������������������



Initials



Inpatient Verbal



Unit/# FAX �����������������



Initials



Copy of Treatment Record in Inpatient Record ���������������������



Initials



Medications given/documented in MAR(s)* ���������������������������



Initials



Verbal Report Given to:



*if inpatient MAR not available, photocopy HD record and send with inpatient Health Care Record LEGEND



Alb AP Appt. AVF AVG BG BM B/P Ca++



- Albumin - Arterial Pressure - Appointment - Arteriovenous Fistula - Arteriovenous Graft - Blood Glucose - Bowel Movement - Blood Pressure - Calcium



Chem. CNS Cont. CVC CVS DW Dx GI/GU Gluc



- Chemical - Central Nervous System - Continuous - Central Venous Catheter - Cardiovascular System - Dry Weight - Diagnosis - Gastrointestinal/Genitourinary - Glucose



HCO3 HD Hgb HR IPN ISO IV K+ kg



- Bicarbonate - Hemodialysis - Hemoglobin - Heart Rate - Integrated Progress Note - Isolation - Intravenous - Potassium - Kilograms



Kt/V L LOC MAR min mL N+V N/A Na+



- Dialysis Treatment Adequacy - Left - Level of Consciousness - Medication Administration Record - Minutes - Millimetres - Nausea and Vomiting - Not Applicable - Sodium



NaCl OT P Pharm Plt PO PO4 Pt. PTH



- Sodium Chloride - Occupational Therapist - Pulse - Pharmacist - Platelets - Per Os - Phosphorus - Patient - Parathyroid Hormone



Punc. Qb R RBV RD Resp RR SOB Stn



- Puncture - Blood Flow Rate - Right - Relative Blood Volume - Registered Dietitian - Respiratory - Respiratory Rate - Shortness of Breath - Station



SW T Tx UF UFC UFR Ven. VP WBC



- Social Worker - Temperature - Treatment - Ultrafiltration - Ultrafiltration Control - Ultrafiltration Rate - Venous - Venous Pressure - White Blood Count



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