Peritoneal Dialysis Clinic Follow-Up Note (Pediatric)

Date of Service: [Date]

Patient: [Patient name and identifiers]

Provider: [Provider name and credentials]

Visit Type: [in-person / telehealth]

Present: [Patient, caregiver(s) with relationship and guardian status, interpreter and language if used]

Reason for Visit: [Reason for pediatric peritoneal dialysis follow-up]

Subjective

Chief Concern: [Primary concern in 1–2 lines] (Include a brief caregiver quote only if it clarifies urgency or context.)

Interval History: [Time since last visit; interim events including hospitalizations, procedures, antibiotic courses] (Attribute source of information when relevant to reliability.)

PD Treatment Course: [Current modality and assistance status; treatment completion; cycler issues or alarms; whether home logs and/or cycler download were reviewed] (If logs or download are unavailable, explicitly state this and note the basis for prescription decisions.)

Volume Status History: [Recent home weights vs dry weight goal; edema symptoms; estimated urine output; home BP readings if available]

Infection Symptom Screen: [Peritonitis symptoms (abdominal pain, cloudy effluent, fever); exit-site or tunnel concerns; contamination events and response taken]

Growth and Nutrition: [Appetite; feeding tolerance; enteral feeds regimen if applicable; bowel regimen adherence]

Medications: [Adherence overview; barriers; side effects; recent changes]

Objective

Vitals/Anthropometrics:

• Weight: [Weight and date] (Specify whether dialysate was subtracted and whether this represents euvolemic/dry weight.)
• Height/Length: [Height and date]
• Blood Pressure: [BP and date with pediatric percentile interpretation]
• Other Vitals: [HR, RR, Temp, SpO2 as relevant]
• Head Circumference: [Measurement and date] (Include for infants/toddlers.)

Exam: (If telehealth, document exam limitations and observations feasible via video.)

• General/Hydration: [Appearance; hydration status]
• Cardiac: [Findings]
• Pulmonary: [Findings]
• Abdomen: [Findings including tenderness, distension]
• Extremities: [Edema assessment]
• PD Access Exam: [Exit site appearance; tunnel assessment; cuff status; dressing status] (Must be explicitly documented.)

Current PD Prescription: (Include date last confirmed.)

• Modality: [APD / CAPD; assisted status]
• Fill volume: [mL] ([mL/kg] or [mL/m²])
• Cycles: [Number of cycles]
• Dwell times: [Dwell durations]
• Total therapy time: [Hours]
• Last fill: [Volume/type; dwell plan]
• Day exchanges: [Volume, frequency, timing if any]
• Solutions: [Concentrations/types]
• Additives: [If currently prescribed]

PD Performance: [Date range of data reviewed; treatments completed vs prescribed; net ultrafiltration; average drain volumes and variability; alarm frequency and types; effluent appearance]

Adequacy: [Total Kt/V with date; dialytic and residual Kt/V components; residual kidney function metrics (urine volume, CrCl); recent PET result and date if available; next adequacy assessment status (due / overdue / pending with planned date)]

Labs: [Relevant results organized by clinical domain with collection dates] (Include pending labs with draw date and interim safety plan if needed.)

Medications: [Medication list reconciled as of date] (Highlight recent changes.)

Assessment & Plan

(Use problem-oriented format. For each problem, include assessment tied to objective data, plan/interventions, and monitoring. Include only clinically relevant problems.)

ESKD on PD: Adequacy and Prescription Management

[Assessment referencing adequacy values, PD performance, and current prescription]

• Plan: [Prescription adjustments, diagnostics, education, coordination]
• Monitoring: [Follow-up metrics, timing, escalation criteria]

New PD Prescription: (Include only if prescription changed; document complete prescription block with rationale.)

• Rationale: [Reason for change tied to data]
• Modality: [APD / CAPD; assisted status]
• Fill volume: [mL] ([mL/kg] or [mL/m²])
• Cycles: [Number of cycles]
• Dwell times: [Dwell durations]
• Total therapy time: [Hours]
• Last fill: [Volume/type; dwell plan]
• Day exchanges: [If any]
• Solutions: [Concentrations/types]
• Additives: [If prescribed]
• Effective date: [Date]

Volume Status and Blood Pressure

[Assessment citing weights vs dry weight goal, edema, urine output, BP with percentiles]

• Plan: [UF target adjustments, diuretics, salt/fluid guidance, BP medications]
• Monitoring: [Home weights/BP schedule; thresholds for contact]

PD Access and Infection Surveillance

[Assessment referencing exit-site/tunnel exam findings, symptom screen, recent cultures]

• Plan: [Exit-site care, prophylaxis, cultures, antibiotics if indicated]
• Monitoring: [Signs to track; criteria for effluent analysis]

Growth and Nutrition

[Assessment referencing anthropometrics with dates, intake/tolerance, bowel regimen]

• Plan: [Dietary goals, enteral regimen, supplements, bowel regimen adjustments]
• Monitoring: [Weight velocity targets; follow-up labs and dates]

Additional Problems

(Include only as clinically relevant.)

• Electrolytes/Acid-Base: [Assessment and plan]
• CKD-MBD: [Assessment and plan]
• Anemia: [Assessment and plan]
• Transplant Coordination: [Assessment and plan]
• Psychosocial/Support Needs: [Assessment and plan]

Education and Technique: [Topics reviewed; whether technique was directly observed and outcome] (If technique was not observed, document explicitly and note retraining or home visit plans if indicated.)

Follow-up

• Next appointment: [Date, time, location or telehealth]
• Interim contacts: [Planned calls or visits and timing]
• Please bring: [Home logs, cycler card/download, medication list, supplies]
• Red flags (call immediately): cloudy effluent, abdominal pain, fever, exit-site drainage, rapid weight gain, breathing difficulty
• PD team contact: [Clinic phone; after-hours instructions]

(Omit sections not clinically relevant to the encounter. Do not infer adherence, technique competency, infection status, or euvolemia without explicit supporting data. When information is missing, document what is unknown and the interim plan. Include explicit dates for all adequacy values, lab results, and prescription parameters.)