Post-AKI Clinic Follow-up Note

Visit Information

Date: [Date]
Patient: [Patient name and identifiers]
Provider: [Provider name and credentials]
Location: [clinic / telehealth]
Hospitalization: [Facility], [admission–discharge dates], discharged to [disposition], [primary diagnosis including AKI] (If hospitalization details are unavailable, write "Unknown—records requested" and note plan to obtain records.)

Subjective

Chief Concern: [One-line, patient-centered reason for visit] (Include brief patient quote only if it adds clinical clarity.)

Interval History: [Narrative summary] (State whether first or subsequent post-discharge visit. Describe post-discharge course including kidney/volume symptoms, urinary changes, intercurrent illnesses, and functional status. Include home BP and weight monitoring if recorded. Document medication adherence and explicitly document NSAID use or avoidance.)

AKI Episode Summary:

• Etiology: [Presumed category and suspected cause] (Only include if documented; do not infer.)
• Baseline Cr: [Value] ([date], [source]) (If unknown, state explicitly.)
• Peak Cr: [Value] ([date])
• Discharge Cr: [Value] ([date])
• KRT required: [yes / no] ([modality and dates if applicable])
• Key exposures: [Precipitants such as volume depletion, sepsis, contrast, nephrotoxins] (Only include if documented.)
• Inpatient workup: [Relevant kidney diagnostics and notable findings] (Include only completed studies.)

(If hospital records unavailable, label elements as patient-reported and document retrieval plan. Do not stage AKI or assert etiology without documentation.)

Relevant History: [Baseline kidney health and key comorbidities] (Include CKD stage, albuminuria history, prior AKI, structural/urologic issues, and comorbidities affecting kidney risk. Include only if relevant and documented.)

Objective

Vitals: [BP] (include orthostatics if symptomatic), [HR], [Weight with trend since discharge]

Exam: [Focused volume status assessment and pertinent cardiac findings] (Document JVP, edema, lung exam, mucous membranes; include cardiac exam if relevant to medication titration.)

Data Reviewed: [Creatinine/eGFR, electrolytes, UACR if obtained, other relevant labs and imaging with dates] (Include only completed results with collection dates.)

Kidney Recovery Trajectory: Baseline Cr [value] ([date]) → Peak Cr [value] ([date]) → Discharge Cr [value] ([date]) → Current Cr [value] ([date]); Interpretation: [recovered to baseline / partial recovery / ongoing AKD / worsening] (Base interpretation strictly on documented values.)

Assessment

[Problem-oriented assessment in order of acuity] (For each problem, state diagnosis or working diagnosis, current status with key supporting data and dates, and contributing factors. Address as applicable: post-AKI recovery or AKD status, CKD status and albuminuria, BP management, volume/HF status, electrolyte disorders, medication safety. If kidney function normalized, still document CKD risk status.)

Plan

Medication Reconciliation: [Sources used and discrepancies with resolution] (e.g., discharge summary, pharmacy records, patient report)

• Nephrotoxins: [Avoidance plan] (Document NSAID and contrast avoidance counseling.)
• RAAS inhibitors: [continue / hold / restart / uptitrate], [agent and dose], [indication], [contraindication assessment], [BMP timing 1–2 weeks after restart or dose change] (Do not restart without recent Cr and K or urgent plan to obtain.)
• SGLT2 inhibitor: [eligible / not eligible / defer], [rationale], [sick-day guidance provided] (Confirm recent Cr and K before initiation.)
• Diuretics: [Agent, dose, adjustment rationale, monitoring plan]
• Other renally-cleared medications: [Dose appropriateness for current eGFR and adjustments if needed]

Monitoring: [Specific labs, timing, and rationale] (e.g., BMP in 1–2 weeks after RAAS changes; UACR at ~3 months for CKD risk stratification if not yet obtained.)

Counseling Provided: [Education topics covered] (Document counseling on increased CKD and recurrent AKI risk, nephrotoxin and contrast precautions, individualized sick-day medication guidance. Note patient understanding.)

Return Precautions: [Triggers for urgent evaluation] (e.g., decreased urine output, symptomatic hypotension, worsening edema or dyspnea, severe vomiting/diarrhea)

Follow-up: [Next lab date], [next visit timeframe] (Clinical review within 3 months per guidelines; sooner if higher risk or active medication titration.)