HEMODIALYSIS TREATMENT SHEET

Patients Name (Last, First & Middle) Age: Ht. Start: H Tx. No. Date
Sex: End: H Patient ID No.

PRE DIALYSIS ASSESSMENT

Dialyzer Use:_______
HD PRESCRIPTION Pre- Hemodialysis PRE ASSESSMENT
MODE Pre Weight Vitals PRE POST Vascular Access: Bruit/Thrill (Pre & Post HD)
DIALYZER Dry Weight BP ↓ []AVF Location ____
TX TIME Rinse Back BP ↑ []AVG Gauge ____
BFR (QB) UF Goal HR []CVC Temporary [] Permanent []
BF (QD) RR Assessment:
Residual
UF Profile Post Hemodialysis Temp
Na Profile Post Weight Spo2 O2 Support:
HDF [] Pre Bld Vol. Pertinent Findings: Hemoglobin PRECAUTIONS:
[]Post Platelet [ ] Standard [ ]Airborne [ ] Droplet
Others: [ ] HBV [ ] HCV [ ]Contact
Subrate Variance
ANTICOAGULATION Kt/v CLINICAL RECORD
Assessment: MEDICATION Time BP AP VP TMP BFR NSS UFR UFV
Time Medication

[ ] UFH
[ ] Regular [ ] Low
[ ] LMWH _______
[ ] NSS
[ ] Other________
Frequency:

RN

INTRADIALYTIC PHASE VITAL SIGNS CURVE

SBP PR RR
200 100
190
180 90
170
160 80
150
140 70
130
120 60 60
110
100 50 50
90
80 40 40
70
60 20 20
50
40 10 10

POST DIALYSIS PHASE

CONDUCTION: [ ] Ambulatory [ ]Wheelchair [ ]Stretcher ID Complication:
Disposition: [ ] May Go Home [ ] For Admission [ ] HAMA

Machine Primed by: Cannulated by: Initiated by: Terminated by Staff Nephrologist/Physician:
 PHYSICIAN’S ORDER SHEET
Patient Name: Age: Patient ID No.
Diagnosis: Sex: Nephrologist:

DATE PROGRESS NOTES ORDERS

 NURSES PROGRESS NOTES
Patient Name: Age: Patient ID No.
Diagnosis: Sex: Nephrologist:

DATE NURSES NOTES DATE NURSES NOTES

 PATIENT DATA SHEET
Patient Name Age Status DOB
Sex Nephrologist
Diagnosis Allergy Blood Type Rh
Permanent Address

Provincial Address

Contact No. Philhealth No. SSS No. Weight Height

BMI BMI Analysis:
Mother’s Name Father’s Name

Spouse Name Contact No.

Address

PERSON(S) TO NOTIFY IN CASE OF EMERGENCY

Name Relationship Address Mobile No. Landline

Previous Dialysis center Date of Initial Dialysis

Physicians Contact No Affiliating Hospitals

Nephrologist Contact No Affiliating Hospitals

Other Doctor & Specialization Contact No Affiliating Hospitals

PHIL- HEALTH MODE OF PAYMENT

Member [ ] Non-Member [ ] Dependent [ ] PCSO [ ] HMO [ ] CARD [ ] CASH [ ]
Philhealth No. Others [ ] Specify________________________
CONSENT FOR HEMODIALYSIS

I ____________________________ hereby authorize the performance of Hemodialysis,

under the direction of Dr______________________.

I have been fully informed by. Dr._________________, MD of the surgical and medical procedures involved, and the problems and risks attendant thereto
necessary to maintain my life in the treatment of my condition, which is chronic kidney failure. I recognize that as with most medical treatment, there are
alternative methods of treatment, but I understand that Hemodialysis is the most likely to be beneficial in the present circumstances.

This consent is for regular and repeated Hemodialysis treatments and for all additional services deemed reasonable and necessary by my physician(s), for the
optimal management of my kidney failure or any complications of the Hemodialysis procedures.

I understand that the Hemodialysis treatment may involve administration of local anaesthetic, insertion of needles into vascular access, administration of
medications and intravenous fluids, which includes by products of blood. The complications from such procedures may include blood loss, infection, sensitivity
reaction and heart failure

______________________________ ______________________________
Print Name/ Signature Witness
______________________________ ______________________________
Date Signed Accomplished by
 PATIENT STATUS
Patient Name: Age: Patient ID No.
Diagnosis: Sex: Nephrologist:

SPECIAL ENDORSEMENT DUE LABORATORIES

Routine Monthly Laboratory
CBC Blood Chem.
Others
Hepatitis Profile
Anti- HBS SGPT
Anti-HCV HBSAG
Hep B vaccine Vaccination
Initial 2mos Flu Vaccine
1mos 6mos Pneumo Vaccine
LATEST LABORATORY
ANEMIA HEMATOLOGY RENAL INVESTIGATION
Hemoglobin (Hgb) Platelet Creatinine
Hematocrit (Hct) RBC BUN Pre
TSAT WBC BUN Post
Ferritin Neutropils URR
Iron Lymphocytes Uric Acid
TIBC Eosinophils ELECTROLYTES
MCV Sodium Phosphorous
Fe Studies Date: MCH Potassium Magnesium
Extraction Date MCHC Calcium
HEPA PROFILE Diabetic Investigation Lipid Profile
SGPT FBS Hba1c Total Cholesterol
SGOT Extraction Date: Triglycerides
HBsag Cardiac Studies LDL
Anti-HCV CPK-MB CRP HDL
Anti-HBS Titer Extraction Date: VLDL
Extraction Date: Others Extraction Date:
LABORATORY REPORT
DATE FINDINGS/ NOTES

MEDICATIONS
Date Route Medication Frequency Date Route Medication Frequency
 HEMODIALYSIS PRESCRIPTION
Patient Name: Age: Patient ID No.
Diagnosis: Sex: Nephrologist:

HD Parameters
Modality

Frequency

Duration

HD Access

Blood Flow

Dialysate Flow

Anticoagulation

Flushing

Bath
Na

Ca

HC03

Erythropoietin

IV Iron

Dry Weight

Physician
Signature

RN Signature

SPECIAL ENDORSEMENT
 LABORATORY FLOW SHEET
Patient Name: Age: Patient ID No.
Diagnosis: Sex: Nephrologist:

Laboratories Normal
Values
BUN Pre
BUN Post
URR
KT/V
Creatinine
BUA
Albumin
Sodium
Potassium
SGPT
IPTH
Calcium
Ca Corrected
Phosphorous
Ca Phos Product
Alk Phosphatase
Hemoglobin
Hematocrit
WBC
Neutros
Lymphos
Eos
Baso
Platelet Count
PT (INR)
PTT
FBS
HBA1C
Total Cholesterol
Triglyceride
HDL
LDL
Ferritin
Serum Iron
TIBC
TSAT

RN Signature

MD Signature
 TREATMENT SUMMARY
Patient Name: Age: Patient ID No.
Diagnosis: Sex: Nephrologist:

BP WEIGHTS HD PARAMETERS Medications RN

Date Pre Post EDW Pre UF Post VAR QB TMP AP VP Kt/v Bld. Complicat Sig
ions
HD HD HD HD Vol.
 VACCINATION RECORD
Patient Name: Age: Patient ID No.
Diagnosis: Sex: Nephrologist:

HEPATITIS B VACCINE INFLUENZA FLU VACCINE (Annually)

CYCLE 1 DATE VACCINE GIVEN REMARKS

DATE VACCINE GIVEN REMARKS GIVEN STICKER BY
GIVEN STICKER BY

PNEUMOCOCCAL VACCINATION (Every 5 years)

CYCLE 2
DATE VACCINE GIVEN REMARKS DATE VACCINE GIVEN REMARKS
GIVEN STICKER BY GIVEN STICKER BY

BOOSTER DOSES OTHER VACCINES

DATE VACCINE GIVEN REMARKS DATE VACCINE GIVEN REMARKS

GIVEN STICKER BY GIVEN STICKER BY
Patient Name: Age: Patient ID No.
Diagnosis: Sex: Nephrologist:

CONSENT FOR HEMODIALYSIS

Dialysis is substitution treatment for kidney function and is intended for persons suffering from advanced kidney
failure. The treatment is essential for maintenance of life but does not result in restoration of health. The dialysis
machine filters and rids the body of waste material, instead of the kidneys. In order to connect the patient to the dialysis
machine, it is necessary to prepare a connection between an artery and a vein by operation (shunt) in one of the limbs.
In certain cases, in the absence of such a shunt, a catheter is inserted temporarily to one of the body’s veins. Insertion of
a needle to the shunt or vein may cause pain and this may be carried out under local anesthetic.

In addition to the dialysis, it is necessary to adhere strictly to a special diet, take certain medications, and adopt a life
style according to instructions from the treatment team.

The treatment is carried out a number of times a week, according to the state of the patient, in a dialysis unit in hospital
or in the community. Every treatment takes a number of hours and after a short rest, the patient may generally return to
usual activity

I hereby authorize the performance of the procedure of Hemodialysis upon

________________________, under the direction of Dr._______________
Name of Patient

I have been fully informed by Dr._____________ , M.D., of the surgical and medical procedures involved, and the
problems and risks attendant thereto necessary to maintain my life in the treatment of my condition, which is chronic
kidney failure. I recognize that as with most medical treatment, there are alternative methods of treatment, but I
understand that hemodialysis is the most likely to be beneficial in the present circumstances.

This consent is for regular and repeated hemodialysis treatments and for all additional services deemed
reasonable and necessary by my physician(s), for the optimal management of my kidney failure or any complications of
the hemodialysis procedures.

I understand that the hemodialysis treatment may involve administration of local anesthetic, insertion of needles
into the vascular access, administration of medications and intravenous fluids, which includes by-products of blood. The
complications from such procedures may include blood loss, infection, sensitivity reaction and heart failure.

______________________
Print Name

______________________ ______________________
Signature of Patient Witness
Or, Parent/Legal Guardian

______________________
Date Signed
Patient Name: Age: Patient ID No.
Diagnosis: Sex: Nephrologist:

PATIENT RIGHTS

The dialysis unit has adopted the following list of patient rights and in accordance with Federal Law
CFR (494.70).

1. The patient has the right to be treated with respect, dignity, and recognition of his or her individuality and personal
needs, and sensitivity to his or her psychological needs and ability to cope with ESRD.

2. The patient has the right to receive all information in a way that he or she can understand.

3. The patient has the right to privacy and confidentiality in all aspects of treatment.

4. The patient has the right to privacy and confidentiality in personal medical records.

5. The patient has the right to be informed about and participate, if desired, in all aspects of his or her care, and be
informed of the right to refuse treatment, to discontinue treatment, and to refuse to participate in experimental
treatment.

6. The patient has the right to be informed about his or her right to execute advance directives, and the facility’s policy
regarding advance directives.

7. The patient has the right to be informed about all treatment modalities and settings, including but not limited to,
transplantation, home dialysis modalities (home hemodialysis, intermittent peritoneal dialysis, continuous ambulatory
peritoneal dialysis, continuous cycling peritoneal), and in-facility hemodialysis. The patient has the right to receive
resource information for modalities not offered by the facility, including information about alternative scheduling
options for working patients.

8. The patient has the right to be informed of facility policies regarding patient care, including, but not limited to,
isolation of patients.

9. The patient has the right to be informed of facility policies regarding the reuse of dialysis supplies, including
hemodialyzers.

10. The patient has the right to be informed by the physician, nurse practitioner, clinic nurse specialist, or physician’s
assistant treating the patient for ESRD of his or her own medical status as documented in the patient’s medical record,
unless the medical record contains a documented contraindication.

Page 1 of 2
Patient Name: Age: Patient ID No.
Diagnosis: Sex: Nephrologist:

PATIENT RIGHTS

The dialysis unit has adopted the following list of patient rights and in accordance with Federal Law
CFR (494.70).

11. The patient has the right to be informed of services available in the facility and charges for services not covered
under Medicare.

12. The patient has the right to receive the necessary service outlined in the patient plan of care.

13. The patient has the right to be informed of the rules and expectations of the facility regarding patient conduct and
responsibilities.

14. The patient has the right to be informed of the facility’s internal grievance process.

15. The patient has the right to be informed of external grievance mechanisms and processes, including how to contact
the ESRD Network and the State survey agency.

16. The patient has the right to be informed of his or her right to file internal grievances or external grievances or both
without reprisal of denial of services.

17. The patient has the right to be informed that she or he may file internal or external grievances, personally,
anonymously or through a representative or the patient’s choosing.

18. The patient has the right to be informed regarding the facility’s policies for transfer, routine or involuntary discharge,
and discontinuation of services to patients.

19. The patient has the right to receive a written notice 30 days in advance of an involuntary discharge except in the case
of a patient who makes severe and immediate threats to the health and safety of others.

_____________________________
Print Name

_____________________________
Signature of Patient
Or, Parent /Legal Guardian

_____________________________
Date Signed

Page 2 of 2
Patient Name: Age: Patient ID No.
Diagnosis: Sex: Nephrologist:

DIALYSIS CENTER RULES & PATIENT RESPONSIBILITIES

Welcome to AGE Group Dialysis Center (Apalit Branch). In an attempt to provide safe and good quality care to
all patients equally, we have established the following dialysis center rules and patient responsibilities:

1. The dialysis center schedules patients for treatment within certain hours. We request patients arrive for their
scheduled treatment 30 minutes prior to their scheduled time. Patients will remain in the lobby until they are called-in
to the clinic by a staff member. Please refrain from walking into the clinic until called as staff members are caring for
others who require their attention. The staff makes every effort to have all patients receive their treatments as
scheduled, however please be respectful of staff and other patients when treatment times are delayed due to
unforeseen circumstances.

2. It is the patient's responsibility to be on time for their scheduled treatment. If the patient is late for dialysis, their
dialysis treatment may be shortened, as it may interfere with the other patients scheduled treatments. Patients need to
inform the clinic if they will not be arriving for their scheduled treatment or need to make schedule changes.

3. Patients who request to travel to other units on a temporary basis are required to provide advance notice to the Social
Worker allowing time for arrangements to be made. We recommend 15- Day notice as many units request updated
vaccinations, lab work, etc., prior to placement. In addition, we must know the return date to this facility. If there is to be
a delay or change in your scheduled return, please notify the unit as soon as possible. If appropriate notice is not given,
your regular scheduled treatment time may not be available.

4. An attempt will be made to have patients be seated at the same chair and pod on a regular basis, however due to
staffing issues and various individual treatment schedules, your chair may be changed from treatment to treatment.

5. An attempt will be made to schedule patients at their preferred shift and time. If the preferred time is not available
you will be placed on a waiting list for that time slot. Scheduling must take into consideration the needs of all the
patients in the unit, therefore, the patient might not always receive the dialysis schedule of their choice.

6. Eating within the dialysis center is not recommended and should be at the discretion of your physician. Visitors are
not allowed to eat in the treatment area.

7. This is a no-smoking facility, which includes the outside premises of the facility

Page 1 of 2
Patient Name: Age: Patient ID No.
Diagnosis: Sex: Nephrologist:

DIALYSIS CENTER RULES & PATIENT RESPONSIBILITIES

Welcome to AGE Group Dialysis Center (Apalit Branch). In an attempt to provide safe and good quality care to all
patients equally, we have established the following dialysis center rules and patient responsibilities

8. Disruptive or unruly behavior in the dialysis center, on the part of a patient or visitor is unacceptable. Any patient who
demonstrates this type of behavior may have their dialysis treatment terminated at that time and requested to leave the
unit. Patients who continue to disrupt the proper functioning of the unit may be involuntarily discharged according to
the facility policy. Visitors will be requested to leave the facility and may be requested to not return.

9. Visitors will not be allowed in the unit while patients are being placed-on or taken-off dialysis. Visitors are expected to
remain with the patient and not wander throughout the clinic, respecting the privacy of other patients. Visitation is
controlled by the Charge Nurse on duty. Children under the age of 14 will not be permitted in the dialysis unit.

10. Patients will apply for Philhealth or other insurance programs when appropriate and to maintain coverage to the best
of their ability.

11. To achieve maximum well-being, patients will notify their physician and medical staff of their medical history and any
medical changes, including changes in medication.

12. Patients will acknowledge that failure to comply with the Nephrologists’ prescribed treatment times and schedule,
medications, diet, and fluid restrictions and other physician’s orders may result in declining health, hospitalization and
possibly death.

I have read and agree to comply with the above dialysis center rules and regulations.

_____________________________
Print Name

_____________________________
Signature of Patient
Or, Parent /Legal Guardian

_____________________________
Date Signed

Page 2 of 2
 PATIENT EDUCATION
Patient Name: Age: Patient ID No.
Diagnosis: Sex: Nephrologist:

TOPIC METHOD EDUCATOR DATE ACKNOWLEDGMENT

 PROBLEM LIST
Patient Name: Age: Patient ID No.
Diagnosis: Sex: Nephrologist:

DATE DATE OF PROBLEM ACTIVE PROBLEMS INACTIVE PROBLEMS ICD CODE

ONSET NO.
I have been advised by that the following treatment, (use of external dialyzer)

Dr. ____________ has fully explained to me the nature, purpose, risks, and benefits of the proposed treatment, the possible
alternatives thereto, and the risks and consequences

I nonetheless consent to the proposed treatment.(use of external dialyzer)

I have been given an opportunity to ask questions, and all of my questions have been answered fully and satisfactorily.

I hereby release the hospital, its employees and medical staff, medical students, and the attending physician from any liability for ill
effects that may result from my decision to refuse to consent to the proposed treatment.

I confirm that I have read and fully understand the above and that all the blank spaces were completed prior to my signing.

Patient/Relative or Guardian* ___________________________

Signature, Print name, Date

Relationship (if signed by person other than patient):

Interpreter (if used): __________________________________

Signature, Print name, Date

*The signature of the patient must be obtained unless the patient is a minor or is otherwise incompetent to sign.

Witness: ____________________________________
Signature, Print name, Date

Physician Certification

I hereby certify that I have explained the nature and purposes of, and alternatives to, the proposed treatment mentioned above, and
the risks and consequences of not proceeding. I have offered to answer any questions and have fully answered all such questions. I
believe that the patient/relative/guardian fully understands what I have explained and answered.

Physician: _________________________________________
Signature, Print name, Date
 MEDICATION LIST
Patient Name: Age: Patient ID No.
Diagnosis: Sex: Nephrologist:

Date Generic Name Route Frequency Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
(Brand Name)

Allergies to Medications: Yes [ ] No [ ] Specify