In-Center Hemodialysis Rounding Note (Interim Visit)

Date/Time: [date and time]

Patient: [patient name/identifier]

Facility/Unit: [facility and station/unit]

Encounter Type: Face-to-face during in-center hemodialysis

Last Monthly Assessment: [date / unknown]

This is an interim hemodialysis rounding visit focused on interval issues; it does not duplicate the monthly comprehensive review unless clinically necessary.

Interval History

[Reason for visit: [routine interim round / problem-focused visit]; patient quote if clarifying: "[patient quote]"]

• [Interval events since last physician encounter] (Hospitalizations, ED visits, missed sessions, new diagnoses, procedures, or medication changes by other providers. If none, state "no interval events.")
• [Dialysis tolerance symptoms — Intradialytic: hypotension, cramps, chest pain, dyspnea, nausea; Interdialytic: edema, orthopnea, fatigue, pruritus] (Use "denies" if asked and negative; "not assessed" if not asked.)
• [Vascular access symptoms] (Cannulation difficulty, prolonged bleeding, swelling, pain, thrill/bruit changes, catheter concerns.)
• [Medication reconciliation status] (Note discrepancies or changes relevant to dialysis care; do not list full regimen.)
• [History source/limitations] (If patient history limited, document reason and alternate sources used.)

Objective

Dialysis Treatment Review:

• [Session status: [ongoing / completed]]
• [Pre-HD vitals as relevant]
• [Pre-HD weight] | [Interdialytic weight gain] | [Estimated dry weight (EDW)]
• [UF goal] | [UF achieved / pending]
• [Treatment time: prescribed vs delivered / pending]
• [Intradialytic events] (Hypotension with nadir BP, cramps, saline boluses, early termination, clotting. If none, state "none.")
• [Recent session trends if pertinent to today's assessment]

Vascular Access Exam: [Access type and location: [AVF / AVG / tunneled catheter] at [site]]

• (For AVF/AVG) [Inspection findings] | [Thrill: [present / absent / weak]] | [Bruit: [continuous / diminished / high-pitched]] | [Cannulation issues] | [Distal perfusion if relevant]
• (For catheter) [Exit site appearance] | [Dressing status] | [Function: [adequate / dysfunction]] | [Infection concerns]
• (If exam deferred, state reason and plan to complete.)

Focused Exam: (Brief, problem-targeted findings only)

• [General appearance]
• [Cardiopulmonary: lung sounds, work of breathing]
• [Volume status: edema, JVP if assessed]
• [Mental status if symptomatic]

Data Reviewed: (Include only data influencing today's plan; omit section if none acted upon.)

• [Pertinent labs with values and dates]
• [Access studies if relevant]
• (If expected labs unavailable, note and document plan to obtain.)

Assessment & Plan

(Problem-oriented format. Include only issues addressed today. For vascular access, include at minimum a brief status statement even if no intervention needed.)

Vascular Access

[Status summary based on exam and function]

• [Plan] (Monitoring, imaging/referral if concern for stenosis or infection, access precautions.)

BP/Volume/Dry Weight Management

(Include only if addressed today.)

• [Assessment of BP trends and volume status]
• [EDW change: [decrease / increase / no change] by [kg], effective [date]]
• [UF strategy adjustments if indicated]
• [Antihypertensive changes: drug, dose, route, frequency, timing relative to dialysis, indication]

Acute Intradialytic Complication

(Include only if applicable — e.g., hypotension, cramps, clotting.)

• [Event summary with objective details]
• [Prevention/management plan for future treatments]

Dialysis Prescription

(Include only if adjusted today.)

• [Component changed] | [New setting] | [Rationale] | [Effective date]

Medication Changes

(Include only if changed today.)

• [[Start / stop / adjust] [drug] [dose] [route] [frequency] [timing relative to dialysis] — [indication]]

Intercurrent Illness/Hospitalization Follow-up

(Include only if applicable.)

• [Diagnosis/issue] — [status update, follow-up plan, referrals]

Follow-up: [Next planned nephrology review]

Safety-net Instructions: [Return/notify triggers discussed: recurrent hypotension, fever/chills, access changes, missed treatments, worsening dyspnea/edema]

Electronically signed by: [physician name, credentials] Date/Time: [signature timestamp]