Monthly Dialysis Management Note (ESRD MCP)

Header

Patient: [Name] • MRN: [MRN] • DOB: [DOB]

Dialysis Facility/Program: [Facility/Program]

Note Type: Monthly Dialysis Management Note (ESRD MCP)

Billing Month: [Start date] to [End date] — [Full coverage / Partial coverage] (If partial: [Dates covered by this MCP practice] due to [hospitalization / modality change / transfer / death])

Dialysis Modality: [ICHD / HHD / PD / mixed] (If mixed, specify modality and corresponding dates)

Date of Signature: [Date] • Author: [Name, Credentials]

MCP Billing Support

(List all ESRD-related visits for the month)

Date	Location	Rendering Clinician	Visit Type	Counts Toward MCP
[Date]	[Location]	[Name, Credentials]	[in-person / telehealth]	[Yes / No]

Vascular Access Examination Attestation: [Hands-on vascular access exam performed on (date) during (location) visit by (clinician), evaluating (access type and laterality). Findings documented below. / Vascular access exam not performed this month due to (reason). Corrective plan: (plan and target date).]

Monthly Assessment Attestation: [Billing clinician name] confirms completion of the comprehensive monthly ESRD assessment, establishment/update of the dialysis plan of care, and provision of at least one qualifying visit within the billing month.

Interval History

Synopsis: [One-line summary: modality, schedule, notable events or "no acute events"]

Dialysis Tolerance: [Intradialytic symptoms, interdialytic issues, overall tolerance]

Attendance: [Missed/shortened treatments with reasons; adherence summary]

Interval Events: [Hospitalizations, procedures, access interventions, infections, transfusions, significant medication changes with dates] (If none, state explicitly)

Objective Data Review

Dialysis Prescription/Delivery: [Modality-appropriate parameters: For HD—frequency, duration, dialyzer, flows, dialysate, dry weight, UF volumes; For PD—modality type, cycler settings, dwells, fill volumes, dialysate strengths, UF, residual output. Focus on current prescription and changes.]

Adequacy: [Most recent Kt/V or URR with date; status relative to target; next adequacy date]

Volume/Vitals: [Pre-/post-dialysis BP trends; interdialytic weight gain; edema; dry weight appropriateness]

Vascular Access Exam: [Access type and laterality] — AVF/AVG: Look: [skin integrity, erythema, aneurysm, steal signs] / Listen: [bruit character] / Feel: [thrill, pulse, tenderness] — CVC: [exit site, drainage, tenderness, tunnel, catheter function] — [Cannulation issues or dysfunction this month] (If exam deferred, state reason explicitly; do not document exam not performed)

Labs: (Summarize with dates) Anemia: [Hb, ferritin, TSAT, ESA/iron dosing] • CKD-MBD: [Ca, Phos, PTH] • Electrolytes: [K, bicarb] • Other: [albumin, other pertinent labs] (If required monitoring missing, document gap and plan)

Medications: [Dialysis-unit administered medications; dialysis-relevant home medications] • Reconciliation: [Statement confirming reconciliation, date, discrepancies addressed]

Assessment & Plan

(Problem-oriented format, highest acuity first. Address core domains: ESKD/adequacy, volume/BP, vascular access, anemia, CKD-MBD, nutrition. Include modality counseling, transplant status, and comorbidities affecting dialysis as relevant. Link orders/referrals to associated problems. Document only month-specific updates.)

[Problem #1]: [Assessment tied to current data] — Plan: [Specific interventions, monitoring, follow-up]

[Problem #2]: [Assessment] — Plan: [Interventions]

(Continue for active problems; for stable comorbidities not affecting dialysis: "Reviewed; no dialysis-related changes")

Orders/Referrals/Coordination: [Labs, medication orders, imaging, referrals, care team communications placed this month]

Sign-off

Signature: [Name, Credentials] • Role: [Billing clinician / Covering] (If multiple clinicians contributed visits, identify clinician responsible for monthly assessment)

(If required elements unavailable—access exam, adequacy, required labs—document explicitly what is missing and plan to obtain)