Pediatric CKD Longitudinal Care Note

Date of Service: [Date]

Location: [Clinic location / Telehealth]

Visit Type: [in-person / telehealth / telephone] — [initial / established follow-up]

Patient Name: [Name]

MRN: [MRN]

DOB / Age: [DOB] / [Age]

Informants: [patient / parent or guardian / other caregiver / interpreter]

Primary Nephrologist: [Name]

Reason for Visit: [CKD follow-up / interval monitoring / medication management / lab review / pre-KRT planning / other]

Chief Concern

[One-line visit focus in patient/family words when available]

Interval History

[Narrative summary of changes since last nephrology visit] (Address intercurrent events, CKD-relevant symptoms, medication adherence and tolerance, diet and fluid adherence, home BP log highlights, and school functioning. For adolescents, include transition self-management tasks practiced. If a critical domain was not assessed, state explicitly: "[Domain] not assessed today due to [reason].")

CKD Longitudinal Summary

• CKD Etiology and Classification: [Etiology], [CKD stage], [eGFR equation used]
• Key Diagnostics: [Imaging, biopsy, genetic results with dates]
• Baseline Kidney Function: [eGFR/creatinine range with dates]; Trajectory Inflection Points: [Events/dates associated with change]
• Proteinuria History: [uPCR/uACR trends with key dates]
• Complication History: [Hypertension, anemia, CKD-MBD, growth failure, metabolic acidosis, electrolyte abnormalities — presence/absence and notable past treatments]
• Prior Therapy Responses: [Response to relevant therapies]
• KRT/Transplant Status: [Pre-KRT planning / dialysis type and access / transplant evaluation status / transplanted with date and donor type] (Omit if not applicable.)

Attestation: Summary reviewed and updated today (changes: [describe updates / none]).

Medications

• [Medication name, dose, route, frequency] — [Indication] — [Adherence: good / occasional misses / poor] — [Tolerance]
• (Include kidney and complication-related medications as applicable: ACEi/ARB, diuretics, bicarbonate/citrate, binders, vitamin D analogs, iron, ESA, growth hormone, immunosuppression.)

Renal Dosing Review: [Doses reviewed for current kidney function; changes made or "no adjustment indicated today"]

(If medication reconciliation incomplete: "Medication reconciliation incomplete due to [reason]; plan to complete by [timeframe].")

Objective

Growth/Vitals:

• Anthropometrics: Height [value] ([percentile/z-score]); Weight [value] ([percentile/z-score]); BMI [value] ([percentile/z-score]) — Change since last visit: [Δ height, Δ weight, Δ BMI]; Growth velocity: [if available]
• Blood Pressure: [Clinic BP] mmHg — [oscillometric / auscultatory], cuff size [size]; [percentile/category]. Home BP: [date range, typical range, mean]. ABPM: [date, interpretation] (if applicable).

Labs and Trends: (Present key parameters across recent timepoints with collection dates. Prioritize trend direction over isolated values. Mark pending labs as ordered.)

• Kidney Function: Creatinine [trend with dates]; eGFR ([equation]) [trend with dates]; CKD stage: [current]
• Proteinuria: [uPCR/uACR trend with dates]
• Electrolytes/Acid-Base: [Sodium, potassium, bicarbonate trends]
• Anemia Indices: [Hemoglobin, ferritin, TSAT trends]
• CKD-MBD Markers: [Calcium, phosphorus, PTH, 25(OH) vitamin D trends]
• Other: [Additional relevant labs] (Include only if pertinent to today's visit.)

Trend Interpretation: [1–3 sentences on direction and clinical significance]

Exam: (Focused CKD-relevant findings. Note telehealth limitations if applicable.)

• General/Hydration: [Appearance, hydration status]
• Cardiovascular: [Heart sounds, rate/rhythm, murmurs]
• Abdomen: [Soft/non-tender, organomegaly]
• Edema: [Absent / present with distribution and severity]
• Skin: [Pallor, other findings]
• Dialysis Access: [Type, site, appearance/function] (Include only if applicable.)

Assessment & Plan

(Organize by problem, ordered by clinical urgency. For stable domains not actively addressed today, include: "Reviewed; stable; next monitoring in [interval]." Omit domains not relevant to this visit.)

[Problem 1]: [Diagnosis/issue] — [stable / improving / worsening / at goal / not at goal]

• Evidence: [Key supporting data with dates/trends]
• Target/Goal: [Specific target]
• Plan: [Medication changes, monitoring intervals, referrals, education, care coordination]
• Contingencies: [Action thresholds and instructions]

[Problem 2]: [Diagnosis/issue] — [status]

• Evidence: [Key data/trends]
• Target/Goal: [Target]
• Plan: [Actions]
• Contingencies: [Thresholds]

(Common domains: CKD stage/progression risk, BP/proteinuria, electrolytes/acidosis, growth/nutrition, anemia/iron, CKD-MBD, school accommodations, psychosocial/care coordination, transition readiness, KRT planning, immunizations.)

Follow-up and Monitoring

• Follow-up: [Interval] — [in-person / telehealth]
• Next Labs: [Labs and timing; ABPM if applicable]
• Result Communication: [Who will communicate and method]