Home Dialysis Monthly Management Note (PD/Home HD)

Date of Evaluation: [date]

Month Covered: [month/year]

Encounter Type: [in-person / telehealth / phone]

Clinician: [name, credentials]

Home Dialysis Modality: [PD: CAPD / PD: APD / Home HD: specify schedule]

Access Type: [PD catheter / AVF / AVG / CVC]

Data Sources Reviewed: [treatment logs / labs / adequacy studies / nursing notes / device downloads] (Select all that apply)

Interval History

[Brief narrative summary] (3–6 sentences. Begin with one sentence identifying the patient's modality and that this is the required monthly assessment. Summarize interval events since last evaluation: hospitalizations or ED visits, symptoms relevant to adequacy or volume status, and adherence barriers. For PD, include peritonitis or exit-site symptoms if present. For Home HD, include intradialytic symptoms and access concerns. If history unobtainable, state why and note reliance on objective data.)

Objective

Vitals/Volume: [Current weight, trend, dry/target weight if used] | [BP summary] | [Volume exam findings and impression]

Treatment Delivery: [Prescribed vs delivered therapy this month] | [Notable missed treatments, alarms, or shortened sessions] | (If treatment logs unavailable, state this explicitly and plan to obtain)

Access Exam: (Required for billing compliance. Document specific findings; avoid vague phrases like "access intact." If not examined, state reason and plan.)

• If PD catheter: [Exit-site appearance, tunnel assessment, catheter function (inflow/outflow)]
• If vascular access: [AVF/AVG: bruit, thrill, aneurysm, cannulation sites, bleeding history] or [CVC: exit-site condition, drainage, stability]

Current Prescription

Effective date: [date]

If Peritoneal Dialysis: [Modality (CAPD/APD)] | [Fill volume] | [Exchanges or cycles] | [Dwell times] | [Dialysate concentrations] | [Additives if any] | [UF goals if used]

If Home Hemodialysis: [Frequency and duration] | [QB/QD] | [Dialysate composition] | [Anticoagulation] | [UF target] | [Cannulation method]

Prescription changes this month: [Old → New, effective date, rationale, who notified] (If none, state "No prescription changes this month.")

Assessment & Plan

(Problem-oriented format. List active problems in decreasing clinical priority. For each, provide concise assessment linking data to clinical status, followed by specific plan with actions and monitoring interval. Include only problems relevant this month.)

Dialysis adequacy: [Most recent Kt/V or URR with date; whether adequate; relation to symptoms/adherence] → [Plan] (If data pending, state this and plan to obtain.)

Volume/BP management: [Weight trend, BP summary, UF, exam correlation] → [Plan]

Access/catheter status: [Summary of exam findings and function] → [Plan]

Infection surveillance: [Explicitly state presence or absence of infection this month. For PD: peritonitis or exit-site/tunnel infection with culture and treatment details if present. For Home HD: access or bloodstream infection concerns. Use explicit negatives, e.g., "No peritonitis this month."] → [Plan if applicable]

Other active problems as indicated: [Electrolytes, anemia, CKD-MBD, nutrition—include only if actionable this month] → [Plan]

(If labs pending with no action taken today, state "Labs pending" with plan/timeline for review. Omit problem categories that do not apply this month. Explicitly state when critical information is unavailable.)

Orders & Communication

Orders: [Prescription changes, medication adjustments, tests ordered] (If none, state "No new orders.")

Communication: [Patient/caregiver notified] | [Home training nurse notified] | [Method and date for each]

(Do not include transplant status, psychosocial concerns, or training updates unless directly impacting this month's clinical decisions.)