Acute Intermittent Hemodialysis Treatment Note (Pediatric)

Date: [Date]

Patient: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Location: [Unit, bed/room]

Documenting Clinician: [Name, credentials]

Indication & Session Goals

[Indication for IHD session and relevant clinical context] (State the explicit indication such as AKI with refractory hyperkalemia, fluid overload, uremic complication, or toxin removal. Include context affecting delivery: hemodynamic stability, vasoactive support, neurologic risk for disequilibrium, high uremic burden, or first dialysis. If IHD selected despite hemodynamic instability, note rationale and mitigation plan.)

• Volume Goal: [Target net ultrafiltration in mL and/or target post-treatment weight in kg]
• Solute Goal(s): [Target electrolyte, pH, or other solute thresholds]
• Toxin Removal Goal: [Toxin name, target endpoint, rebound monitoring plan] (Include only if toxin or endogenous solute removal is indicated.)

Pre-Dialysis Assessment

• Baseline Vitals: [HR, BP, RR, SpO2, temperature with time]
• Respiratory/Hemodynamic Support: [Current support] (Include vasoactive agents with doses, ventilation settings if applicable; state "None" if not on support.)
• Mental Status: [Baseline mental status]
• Pre-Dialysis Weight: [Weight in kg] ([measurement method])
• Target/Dry Weight: [Established target weight] (If not established, state that UF goal is based on clinical assessment or intake/output data.)
• Pertinent Pre-Dialysis Labs: (Include collection time for each.)
  • [Electrolytes, bicarbonate or blood gas]
  • [BUN, creatinine]
  • [CBC, platelets] (If relevant to anticoagulation.)
  • [Glucose] (Include in small children.)
  • [Toxin or ammonia level] (If applicable.)
• Medications Impacting Dialysis: [Anticoagulants/antiplatelets, antihypertensives, dialyzable antibiotics requiring timing coordination]
• Anticoagulation Eligibility: [planned / minimized / avoided] — [Rationale] (State reason such as thrombocytopenia, active bleeding, recent surgery, or HIT history.)

(If a safety-critical value such as weight or key lab was not obtained, explicitly state "Not obtained" with reason and mitigation.)

Access & Circuit

• Access Type: [Temporary catheter / Tunneled catheter / AV fistula / AV graft] — [Site and size or location]
• Access Assessment: [Assessment findings] (For catheters: dressing condition, infection signs, patency. For AV access: bruit/thrill, skin integrity, prior complications. If AV cannulation performed: needle gauge, technique, attempts, complications.)
• Circuit Plan: [Tubing and dialyzer model/size with rationale based on patient weight]
• Prime Strategy: [Crystalloid / Blood / Albumin prime] (Document product type, volume, disposition. For small patients where extracorporeal volume exceeds 10% blood volume, document mitigation strategy.)

Prescription (Ordered)

• Dialyzer: [Model/type]
• Blood Flow: [mL/min] ([mL/kg/min])
• Dialysate Flow: [mL/min]
• Planned Duration: [hours:minutes] (Note if staged or shortened first run.)
• Dialysate Composition: K [value], Ca [value], Na [value], HCO3 [value], glucose [if nonstandard], temperature [if cooled]
• Ultrafiltration Goal: [Target net UF in mL and/or target post weight in kg] (Note UF profiling, sodium modeling, or blood volume monitoring if ordered.)
• Anticoagulation Plan: [Agent, bolus dose, infusion rate, stop time before end, monitoring approach] (Or state "None — saline flush strategy.")
• Special Instructions: [Hemodynamic thresholds for notification, toxin protocol specifications, other specific instructions]

Treatment (Delivered)

• Start Time: [Time]
• End Time: [Time]
• Total Run Time: [Duration] (Calculated)
• Completion Status: [Completed as prescribed / Completed with modifications / Terminated early / Aborted before initiation] (If terminated or aborted, include reason and whether circuit blood was returned.)

Delivered Parameters:

• Blood Flow: [Actual range mL/min]
• Dialysate Flow: [Actual mL/min]
• Dialysate Composition: [Actual composition, noting any changes from ordered]
• Dialysate Temperature: [Actual temperature]
• Anticoagulation Given: [Bolus dose/time, infusion rate/changes, total dose] (Or "None" with saline flush details.)

Fluid and Ultrafiltration Accounting:

• Total UF Removed: [mL]
• Intradialytic Fluids Administered: [Type and volume for each]
• Net UF Delivered: [mL] (Calculated)
• UFR: [mL/kg/hr] (Calculated)
• Pre-Dialysis Weight: [kg] Post-Dialysis Weight: [kg] Weight Change: [kg] (Calculated)

Intradialytic Medications/Transfusions: [Name, dose, route, time, indication for each]

Deviations from Prescription: (Document each deviation with time, parameter changed, reason, and authorizing clinician.)

• [Time] — [Parameter] — [Change made] — [Reason] — [Authorizing clinician]

Intradialytic Course

• Vital Sign Monitoring: [Frequency] (Note any deviation from planned cadence.)
• Symptom Assessments: [Symptoms assessed] (Include headache, nausea, cramping, chest pain, chills.)

Significant Events: (Document chronologically with time-stamped entries.)

• [Time] — [Problem] — [Supporting data] — [Intervention] — [Response/outcome] — [Who notified]

Intradialytic Adjustments: (Include reason, time, and authorizing clinician for each.)

• [Time] — [Adjustment] — [Reason] — [Authorizing clinician]

Post-Dialysis Assessment

• Post-Treatment Vitals: [HR, BP, RR, SpO2, temperature with time]
• Mental Status: [Post-treatment mental status and symptom resolution or persistence]
• Post-Dialysis Weight: [kg] (Compare to target.)
• Access Status: [Post-treatment access condition] (For AV access: hemostasis time, bleeding, hematoma, dressing. For catheter: dressing, cap change, lock solution type and volume per lumen, patency.)
• Estimated Blood Loss: [mL or "Minimal"] (Document if abnormal.)
• Post-Dialysis Labs: [Labs ordered or obtained with timing] (For toxin removal, specify next level timing and rebound monitoring plan.)
• Immediate Complications: [Complications and management] (State "None" if none occurred.)

Assessment & Plan

[Session summary and goal attainment] (State whether volume goal was met/partially met/not met with reason. For solute/toxin goals, describe trajectory based on available data; do not claim success without supporting post-dialysis results. Include tolerance statement referencing objective data such as vitals, interventions, and events.)

• Next RRT Plan: [None / Repeat IHD with timing / Transition to CRRT or PD / Reassess]
• Access Plan: [Access-related actions or monitoring]
• Anticoagulation Plan: [Approach for next session] (Informed by clotting or bleeding this session.)
• Medication Coordination: [Timing for dialyzable medications]
• Escalation Instructions: [Thresholds for contacting nephrology]

(Do not include adequacy metrics such as Kt/V or URR unless explicitly provided. Do not infer tolerance or goal attainment without documented supporting data.)