CKD Follow-up Note (Nephrology)

Date/Time: [Date and time of encounter]

Patient: [Patient name and identifiers]

Provider: [Clinician name and credentials]

Encounter Type: [in-person / telehealth]

Last Nephrology Visit: [Date]

CKD Context

• Stage/Category: [CKD G-stage and albuminuria category]
• Etiology: [Suspected / biopsy-proven / unknown etiology]
• Baseline eGFR: [Value and approximate timeframe]
• Current Kidney-Protective Therapy: [Active agents: RAASi, SGLT2i, ns-MRA, statin, other]
• KRT Planning Status: [Not indicated / Education initiated / Modality selected / Access planning / Transplant referral status] (Include only for CKD G4-G5 or high-risk progression.)

Interval History

[Interval events since last visit] (Summarize hospitalizations, AKI episodes, procedures, contrast exposures, medication changes by other providers, nephrotoxin exposures. Document source of history if not the patient.)

[Current symptoms and home monitoring] (Include volume-related symptoms, uremic symptoms if advanced CKD, anemia symptoms. Include home BP range with measurement technique, weight trend, dietary adherence, medication adherence and barriers.)

Medications

Reconciliation: [Completed / Not completed] with [patient / caregiver / pharmacy records / EMR]

Active Medications: [Kidney-protective and BP agents, diabetes agents if applicable, potassium management, acidosis therapy, anemia therapy, CKD-MBD therapies, other relevant medications with doses] (Group by clinical role. Note nephrotoxic risk medications.)

Allergies: [Allergy list with reactions / Not confirmed today]

Objective

Vitals: BP [value and method if standardized], HR [value], Weight [value] (Note orthostatics if obtained.)

Exam: [Volume status assessment with supporting findings] (Document JVP, edema with grade and distribution, lung exam, weight change interpretation. Include other pertinent findings only. Do not auto-populate normals.)

Lab Trends:

Date	Cr / eGFR	K	HCO3	UACR/UPCR	Hgb	Ca	Phos	PTH
[Date 1]	[Value]	[Value]	[Value]	[Value]	[Value]	[Value]	[Value]	[Value]
[Date 2]	[Value]	[Value]	[Value]	[Value]	[Value]	[Value]	[Value]	[Value]
[Date 3]	[Value]	[Value]	[Value]	[Value]	[Value]	[Value]	[Value]	[Value]

[Trajectory interpretation] (State whether trends are stable or show progressive decline; correlate inflection points with events or medication changes. If key labs unavailable, state the gap and what was ordered.)

Assessment & Plan

(Organize by active problems in order of clinical priority. Include only problems relevant to this encounter. For each problem: assessment tied to trend data, specific interventions with action labels [Start / Stop / Increase / Decrease / Continue / Hold], and monitoring plan with timing.)

CKD Progression

Assessment: [Stage, trajectory, and risk interpretation]

[Kidney-protective therapy adjustments with action labels] [Nephrotoxin avoidance status] [Monitoring plan and timing]

Blood Pressure / Proteinuria

Assessment: [BP control status referencing home and clinic values; albuminuria trend]

[Antihypertensive adjustments with action labels and doses] [Home BP plan: frequency, targets] [Monitoring plan and timing]

Volume Status

Assessment: [Euvolemic / hypervolemic / hypovolemic] with supporting evidence

[Diuretic adjustments with action labels and doses] [Sodium restriction and weight monitoring instructions] [Monitoring plan and timing]

Hyperkalemia

Assessment: [Potassium trend and contributing factors]

[Dietary counseling, binder, or medication adjustments with action labels] [RAASi continuation rationale if maintained despite elevated K] [Monitoring plan and timing]

Metabolic Acidosis

Assessment: [Bicarbonate trend; volume and pill burden considerations]

[Alkali therapy adjustments with action labels and target range] [Monitoring plan and timing]

Anemia of CKD

Assessment: [Hemoglobin trend and iron status]

[Iron, ESA, or HIF-PHI therapy with action labels, dosing, and indication] [Monitoring plan including Hgb, iron indices, and safety parameters]

CKD-MBD

Assessment: [Integrated interpretation of Ca/Phos/PTH trends; vitamin D status]

[Vitamin D, calcimimetic, or phosphate binder adjustments with action labels] [Dietary phosphate counseling] [Monitoring plan and timing]

KRT Planning

(Include for CKD G4-G5 or high-risk progression only.)

Assessment: [Progression risk; patient education status and preferences]

[Modality discussion status and next steps] [Access planning: vascular access or PD catheter referral and timing] [Transplant referral status with rationale] [Next milestone and follow-up cadence]

Orders & Follow-up

Labs: [Tests ordered with timing and indication]

Referrals: [Referrals or imaging with indication]

Patient Instructions: [Medication changes in plain language] [Home monitoring: BP and weight frequency and targets] [Dietary guidance specific to this patient] [Red flags for return: rapid weight gain, severe weakness, dyspnea, decreased urine output]

Follow-up: [Timing and modality of next visit; criteria for earlier return]

Data Limitations: [Critical information missing and plan to obtain] (Include only if key data unavailable for decision-making.)