FORUM OF ESRD NETWORKS/THE NATIONAL KIDNEY FOUNDATIONUNIFORM ESRD TRANSIENT HEMODIALYSIS FORM
PATIENT INFORMATION
Patient Name:

DOB / / Sex Marital Status_________________
Last
First
Parent or Legal Guardian (If Minor)________________________________________________________________
Address:_______________ Phone: (H) ___________(W)__________

SSN#

HIC#

______Date of first Dialysis

ESRD Diagnosis: Primary//Secondary_________________________________________

Treatment Dates Requested//-//Total # of Treatments__________________________

Preferred Time:_________________________________REFERRING DIALYSIS UNIT INFORMATION
Referring Unit Name

Phone

Fax__________________

Contact Nurse

Social Worker

Primary Nephrologist

Phone

Fax__________________

Emergency Pt. Contact Name__________________________Relationship________Phone (H) ________________
Phone (W)________________
LOCAL RESIDENCE INFORMATION (TRANSIENT CITY)
Local Address or Hotel

Phone________________

Emergency Contact

RelationshipPhone________________

Admitting Nephrologist

Phone________________CURRENT TREATMENT ORDERS___________ Home
Dialyzer:___________ In-Center Hemo____________ Self Care______________Reuse? ___Yes ___ No

Blood Flow_________ Dialysate Flow

Treatment Type_____ Conventional_____ High Flux_____ High Efficiency
Times Per Week____________ Staff Assisted

Volumetric ______Yes ______No

Prescribed Time

Dialysate Rx: K+______ CA++_______ Dextrose_______ Sodium________ Bicarb_________ Acetate_________
Sodium Modeling:
Dry Weight#kg _______________#lb

Heparinization Method
If pump, DC

Total Units____________________________
hr/min. pretreatment termination
VASCULAR ACCESS

Vascular Access: Type ___________________ Location________________ Flow Direction___________________
Local Anesthetic ___ Yes ___ No

Usual Venous Pressure_________ Diagram:___________________________

Other special cannulation considerations: i.e., needle gauge, self-cannulation

Vascular catheter special flush instructions

UNIFORM ESRD TRANSIENT HEMODIALYSIS FORM - PAGE 2
PATIENT SPECIFIC INFORMATION:(SYNOPSIS OF UNIQUE CHARACTERISTICS OF PATIENT’S TREATMENTS)
Allergies:_____________________________________________________________________________________
Patient’s trends and usual response to treatment_____________________________________________________
Inter dialytic wt. gains_____________# kg

B/P range: Pre________Intradialytic_______Post____________

Usual BP support methods_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Unusual reactions or need___________________________________________________________________________________________________________________________________________________________________
Special needs or circumstances relative to transient visit_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________INTRADIALYTIC MONITORING:IF APPLICABLE, OTHERWISE NOTE “N/A”

Special Labs__________________________________________ Blood glucose____________________________
Intradialytic treatments: Dressings___________________ O2 ____________________Other__________________EPO

Yes

No

Units_________SQ

Calcijex _____Yes ______No___________ Mcg

IVx’s/week__________X’s/Week

Intradialytic meds: (i.e., Infed)____________________________________________________________________
Mobility:________Ambulatory

Non-Ambulatory

Ambulatory with assist

Special Dietary Considerations____________________________________________________________________
Intradialytic Nutrition Orders__________________________________Fluid Restriction_______________________
ENCLOSURES:______ Standing Orders

CHECK INDICATES INFORMATION SENT FROM HOME FACILITY______ Advance Directive, if applicable

Problem list (Last 6 months)______ Current H & P (within 1 year)

Medication record (home and in-center)______ Hemo last 3 treatment records

Most recent psycho-social evaluation______ Long-term care plan (current year)

Patient care plan (most recent within 6 months)______ Most recent nutritional assessment

Progress note (past 3 months to current)______ Diagnostic tests:_______EKG

MDRN

CXR (within 2 years)

HBsAg status____Positive____Negative Date______ HbsAB status ___Positive____Negative Date

/

RDMSW

Laboratory profile (within last 30 days)///

Vacine series complete___Yes ____No

Insurance information, carrier name & address current copies (front & back) of the following:
Medicare card

Co-insurance card(s)other (specify)____________________________________

TRANSPLANT LIST INFORMATION (IF APPLICABLE) FOR SEASONAL PATIENTS ONLY
LRDCadaver
Transplant facility name and address______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Contact Person________
Phone_____________________________________
SPECIALINSTRUCTIONSPATIENT IS NOT ACCEPTED UNTIL OFFICIAL NOTICE IS RECEIVED FROM RECEIVING UNIT.
Signature__________________________________Title_________________________Date(Referring unit person who completes form)//