CKD Initial Evaluation Note (Nephrology)

Date/Time: [Encounter date and time]

Location: [Clinic / Hospital unit]

Visit Type: [New Patient / Initial Evaluation]

Referral Source: [Referring clinician or service]

Referral Question: [Specific question or concern prompting nephrology referral]

Data Sources: [patient / caregiver / outside records / interpreter] (Note any limitations such as missing records, language barrier, or incomplete history.)

Chief Complaint

[Presenting kidney-related concern] (One to two lines summarizing the reason for referral. If no explicit chief complaint, restate the referral question.)

History of Present Illness

[Narrative chronology of kidney disease evaluation] (Begin with the referral trigger, then the kidney timeline. Include: (1) First abnormal kidney marker and date; evidence of persistence ≥3 months or explicitly state chronicity not yet established; (2) Trend summary of baseline vs recent creatinine/eGFR with dates; (3) Prior AKI episodes with cause, timing, and recovery if known; (4) Current kidney-related symptoms: edema, dyspnea, weight changes, uremic symptoms, foamy urine, nocturia, hematuria, stone/UTI history; (5) Etiology clues: diabetes duration and microvascular disease, hypertension duration/severity, family history of kidney disease, autoimmune/systemic symptoms, obstructive symptoms, nephrotoxin exposures. For missing data, state unavailable rather than inferring.)

Relevant History

Past Medical History:

• [Kidney-relevant conditions] (Prioritize: diabetes, hypertension, ASCVD/heart failure, gout, autoimmune disease, chronic infections, malignancy, prior AKI, dialysis, transplant, solitary kidney.)

Surgical History:

• [Relevant procedures] (Urologic/vascular procedures, kidney biopsy, bariatric surgery, contrast-heavy procedures.)

Family History:

• [Kidney-focused family history] (ESRD, dialysis/transplant, polycystic kidney disease, hereditary nephritis, kidney stones.)

Social History:

• [Tobacco, alcohol, substance use]
• [Dietary patterns and social determinants affecting adherence] (Include if relevant to kidney disease or plan.)

Allergies: [Drug and other allergies with reactions] (If none: "No known drug allergies." If unknown: "Allergy history unavailable; will confirm.")

Medications:

• [Medication list with dose, route, frequency] (Flag RAAS inhibitors, SGLT2 inhibitors, diuretics, NSAIDs, and renally cleared medications. Note renal dose adjustments needed or nephrotoxic potential. If incomplete, state explicitly with plan to reconcile.)

Review of Systems

• Constitutional: [Fatigue, weight change, fevers/chills]
• Cardiopulmonary: [Dyspnea, orthopnea, chest pain]
• GI: [Nausea, vomiting, anorexia]
• Neurocognitive: [Confusion, sleep disturbances, neuropathy]
• Skin/Joints: [Rash, pruritus, arthralgias, edema]
• GU: [Hematuria, dysuria, nocturia, frequency/urgency, flank pain, urine output changes]

(Include targeted positives and pertinent negatives only.)

Objective

Vitals: [BP, HR, weight, BMI] (Note if standardized BP measurement. Include home BP summary if available.)

Physical Exam:

• Volume status: [JVP, edema distribution/grade, lung crackles]
• Cardiovascular: [Heart sounds, pulses, bruits if indicated]
• Pulmonary: [Breath sounds, respiratory effort]
• Abdomen: [Distension, tenderness, bladder fullness if relevant]
• Skin/Joints: [Rashes, lesions, stigmata of systemic disease]
• Neurocognitive: [Asterixis, orientation] (Include if uremia suspected.)

(Only include systems examined.)

Data Review: (Include date for every key value. If unavailable, state and include retrieval in plan.)

• Kidney function: [Creatinine/eGFR trend with dates]
• Proteinuria: [Urine ACR or protein quantification with dates]
• Electrolytes: [Potassium, bicarbonate with dates]
• CKD-MBD: [Calcium, phosphate, PTH, 25(OH)D with dates] (If available.)
• Anemia: [Hemoglobin, ferritin, TSAT with dates] (If available.)
• Metabolic: [A1c, lipids with dates] (If relevant.)
• Urinalysis: [Protein, blood, sediment findings with date]
• Imaging: [Renal ultrasound or other imaging with date] (Kidney size, echogenicity, obstruction, cysts.)
• Outside records: [Source and date range reviewed]

Assessment and Plan

(Problem-oriented format, highest risk first. Omit problems not relevant to this patient. Do not infer definitive CKD diagnosis when chronicity is unestablished; use "suspected CKD" with plan to confirm.)

Problem 1 — CKD (CGA: Cause [known / suspected / unknown] / G[1–5] / A[1–3])

Assessment: [Anchor statement] (State whether CKD criteria met with chronicity established, or suspected CKD pending confirmation. Provide CGA classification: Cause, GFR category G1–G5, Albuminuria category A1–A3. Include CGA risk category. For G3–G5, include kidney failure risk estimate with inputs, date, time horizon, and management implications.)

Etiology: [Suspected cause(s) with ranked differential of 2–4 possibilities if uncertain] (Include supporting and contradicting evidence. Flag findings requiring urgent workup: rapid eGFR decline, active sediment, nephrotic syndrome, systemic features.)

• Workup: [Tests and timing] (Repeat creatinine/eGFR and ACR; UA with microscopy if GN suspected; reversible contributors; etiology-directed tests only if phenotype suggests. Document if test deferred and why.)
• Management: [Renoprotective therapies, BP/glycemic targets, dietary guidance, medication adjustments, nephrotoxin avoidance]
• Monitoring: [eGFR and albuminuria frequency based on risk; thresholds triggering re-evaluation; post-medication-change labs]

Problem 2 — Hypertension and Volume Management

(Include when applicable.)

• Assessment: [BP control status, measurement context, volume status]
• Plan: [Individualized BP target with rationale; medication adjustments; diuretic strategy; dietary sodium guidance; timing for post-change labs]

Problem 3 — Diabetes Management

(Include when applicable.)

• Assessment: [A1c with date, glycemic control, hypoglycemia risk in CKD]
• Plan: [Renal-protective agents (SGLT2i, GLP-1 RA); dose adjustments for CKD; sick-day guidance]

Problem 4 — CKD Complications

(Include relevant subsections only.)

• Anemia: [Hemoglobin, ferritin, TSAT with dates; differential; treatment/evaluation plan] (If no recent labs, order.)
• CKD-MBD: [Calcium, phosphate, PTH, 25(OH)D with dates; monitoring frequency; treatment approach based on trends]
• Electrolytes/Acid-Base: [Potassium and bicarbonate trends; contributors; dietary counseling; medication management]

Problem 5 — Cardiovascular Risk and Nephrotoxin Stewardship

• ASCVD: [Risk level or history; lipid management plan]
• Nephrotoxin avoidance: [NSAID counseling; medication review]
• Contrast planning: [Risk mitigation if upcoming imaging]
• Renal dose adjustments: [Changes made or planned]

Problem 6 — Kidney Replacement Therapy Planning

(Include when eGFR <20, rapid progression, or 2-year kidney failure risk >10%.)

• Assessment: [Readiness and transplant candidacy]
• Plan: [Modality education provided; transplant and access referral timing; if not indicated, document reassessment criteria]

Patient Education

• [CKD stage explanation in patient-friendly terms]
• [Medication changes and monitoring schedule]
• [Sick-day guidance] (When relevant.)
• [Dietary priorities]
• [Red-flag symptoms: worsening edema, shortness of breath, decreased urine output, confusion, severe weakness]
• [Patient preferences] (When treatment choices exist.)

Orders and Follow-Up

Labs: [List with timing: today / in X weeks / before next visit]

Imaging: [Study and indication]

Referrals: [Dietitian / Transplant / Vascular surgery / Urology as applicable]

Follow-Up: [Nephrology follow-up timing; required data before next visit]

Communication: [PCP notification; patient portal message; outside records requested]