Kidney Replacement Therapy Education & Modality Choice Note

Date/Time: [Date and time of encounter]

Location: [clinic / telehealth / inpatient consult]

Patient: [Patient name and identifiers]

CKD Stage / eGFR: [CKD stage]; [Most recent eGFR value and date]; [Trajectory: stable / declining / improving]

Participants: [Patient, family/caregivers present, interpreter and language if used, educators involved]

Decision-Making Capacity: [patient has capacity / patient lacks capacity—if lacks capacity, identify surrogate and legal basis]

Clinical Context

[Brief rationale for initiating KRT planning now, including CKD etiology if known, eGFR trajectory, and comorbidities that materially affect modality suitability such as heart failure, vascular disease, prior abdominal surgery, frailty, cognitive impairment, or housing instability. Include functional status and caregiver availability only if relevant. Reference any prior KRT education encounters or changes in preferences.]

Shared Decision-Making and Education

Modality options presented: [in-center hemodialysis / home hemodialysis / peritoneal dialysis / kidney transplant (living and deceased donor) / conservative kidney management] (Document all options discussed. If any option was not discussed, briefly note why it was deferred.)

Individualized education: [For each modality discussed, summarize key points covered and how they relate to this patient's situation, goals, and constraints. Focus on tradeoffs most relevant to decision-making rather than generic modality descriptions.]

Patient goals and values: [Patient-identified priorities, acceptable and unacceptable tradeoffs, home environment constraints, support system, and cultural or financial considerations affecting feasibility] (Include at least one direct patient quote when available.)

Understanding assessment: [Method used such as teach-back, what patient demonstrated understanding of, misconceptions corrected, and educational materials provided]

Decision Status

Current Status: [chosen / leaning toward / undecided / deferred]

Preferred Modality: [modality, or "none yet" if undecided]

Provisional or Final: [provisional / final]

[Narrative linking patient's stated goals to tradeoffs discussed and current preference. Document unresolved questions and information needed before finalizing. If patient declines a modality—especially transplant—document the decline, stated reason, and plan to revisit.]

Plan

• Education: [Upcoming classes, nurse educator sessions, peer mentor, decision aids—with responsible party and timeframe]
• Access planning: [Vascular access referral if HD likely; PD catheter evaluation if PD likely—with responsible party and timeframe]
• Transplant: [Referral status, living donor discussion, required testing—with responsible party and timeframe] (If declined, document reason and plan to revisit.)
• Conservative management: [Supportive care or palliative care referral if applicable]
• Follow-up: [Next visit timing, labs needed, triggers for earlier contact]
• Contingency: [Urgent symptoms reviewed and plan if urgent dialysis needed before access is ready]

(For high-stakes items—capacity, interpreter needs, transplant interest, home feasibility—document explicitly as "not yet assessed" if unknown. If a modality was not discussed because it was declined or clinically deferred, document this briefly.)