Nephrology Inpatient Progress Note

Date/Time: [Date] [Time]; Author: [Author name, role, credentials]; Supervising Attending: [Attending name, credentials] (Include only if applicable); Patient: [Patient identifiers per institutional standard]; Location: [Unit/Room/Bed]; Hospital Day: [#]; Consult Day: [#]; Today's Focus: [Primary reason for nephrology follow-up today]

Renal Snapshot

[1–2 sentence summary of renal syndrome, trajectory, suspected etiology, RRT status if any, and dominant active constraints. State explicitly if baseline kidney function is unknown.]

Subjective

(Omit entirely if patient is non-communicative and no interval events occurred.)

Interval events: [Key events since last note affecting renal status: hypotension, sepsis, procedures, contrast exposure, etc.] (If none, state "No significant interval events.")

Symptoms: [Relevant patient-reported symptoms: dyspnea, edema, urinary symptoms, uremic features] (If unable to obtain, state why.)

RRT tolerance: [Cramping, hypotension, access issues, early termination] (Include only if on dialysis/CRRT.)

Objective

Vitals: [BP/MAP, HR, Temp, RR, SpO2]; [Pressor support if applicable] (Highlight trends relevant to renal perfusion.)

I/O and Weight: I: [Volume] / O: [Urine output with oliguric/nonoliguric characterization, other losses] / Net: [Net over defined interval]; Cumulative net: [Value]; Weight trend: [Values with dates] (If I/O unreliable, state explicitly.)

Volume Exam: JVP [finding]; Lungs [finding]; Edema [location and grade]; Access [HD catheter/AVF/AVG/PD catheter exam if applicable] (Document only pertinent volume-relevant findings.)

Labs: Cr trend: [Baseline with date/source] → [Admission] → [Today]; BUN [trend], K [trend], Na [trend], HCO3 [trend], Ca/Mg/Phos [as relevant]; Urine studies: [UA, urine lytes, FeNa/FeUrea, sediment findings if obtained]; AG [value], Lactate [if relevant] (If baseline Cr unknown, state this and note sources checked.)

Nephrotoxins/Renal Dosing: [Current exposures: contrast, NSAIDs, aminoglycosides, vancomycin, ACEi/ARB, etc.]; [Dose adjustments needed]

Diuretic Response: [Agent/dose] → [Urine output response] (Include only if on diuretics.)

RRT Data: [Modality], [Access], [Last session date with UF achieved], [Key prescription elements], [Complications] (Include only if on RRT.)

Assessment & Plan

(Problem-oriented; highest acuity first. For each problem, state brief assessment then today's specific plan. State what changed since yesterday.)

[Problem 1]

Assessment: [Synthesis including severity/stage, trajectory, etiology, key supporting data]

Plan: [Specific actions: tests, medication changes with doses, targets, monitoring parameters]

[Problem 2]

Assessment: [Brief synthesis]

Plan: [Specific actions]

(Continue for additional problems. Common nephrology problems to address when present: AKI/AKD with KDIGO stage and etiology; volume status with target; electrolyte disorders; acid-base disturbances; RRT management with explicit documentation of urgent indications present or absent; medication safety.)

Recommendations to Primary Team

• [Specific order or action item]
• [Monitoring instruction with parameters]
• If [condition/threshold], then [action]

(Page nephrology for rapid deterioration, refractory electrolyte derangements, or new RRT indications.)

Electronic Signature: [Name, Credentials] — [Date/Time]

Attending Attestation: [Attestation statement] (Include if trainee note per institutional policy.)