Vascular Access Evaluation and ESKD Life-Plan Note

Date/Time: [Date and time of encounter]

Encounter Type: [new evaluation / follow-up / annual life-plan update / post-op follow-up / problem-focused]

Location: [Location and service setting]

Referral Source: [Referring clinician or service]

Access Summary

(Provide an at-a-glance snapshot. Document "unknown" rather than leaving blank.)

• Current KRT status: [pre-dialysis CKD / hemodialysis / peritoneal dialysis / transplant / conservative management]
• Current access type and site: [Access type with laterality and anatomic location]
• Access age: [Time since creation/placement or unknown]
• Current usability status: [fully usable / maturing / limited use / not usable / on hold / unknown]
• Immediate risk flags: [suspected infection / suspected steal-ischemia / aneurysm skin risk / repeated dysfunction / limited remaining access sites / none] (Select all that apply.)
• Next planned milestones: [Vessel mapping target date] | [Surgical/IR referral target date] | [Access creation target date] | [Expected cannulation readiness] | [Catheter removal goal]

Key Contacts

Primary nephrologist: [Name, contact/routing]

Vascular access interventionalist: [Name, contact/routing]

Vascular surgeon: [Name, contact/routing]

Dialysis facility and shift: [Facility name, unit contact, shift details]

Primary care clinician: [Name, contact/routing]

Transplant center: [Center, listing status, contact/routing]

Interpreter needs: [Language and modality / none]

Indication for Evaluation

[Clinical trigger for this evaluation] (State the reason: progressive CKD with recent eGFR trend; HD with access strategy change needed; PD with transition concern; failing transplant with return to dialysis anticipated; or access complication requiring re-planning. Specify whether this is an initial life-plan, annual review, or interim revision. If prior life-plan exists, state its date and whether it has changed. If unchanged, document "reviewed—no change" and reaffirm monitoring plan.)

Patient Goals and Shared Decision-Making

• Participants: [Patient, caregivers, interpreter, team members present]
• Patient-centered goals and priorities: [Home vs in-center preferences, schedule constraints, catheter avoidance priority, arm function preservation, hand dominance, lifestyle factors, cosmetic considerations] (Only document what was explicitly stated.)
• KRT options discussed and outcomes: [Transplant evaluation/waitlist status; PD feasibility; home HD vs in-center HD; conservative management; outcome of each discussion] (Do not infer preferences or consent.)
• Decision status: [Modality decision: made / pending] | [Access strategy decision: made / pending] (If pending, note reason and next steps.)
• If goals not elicited: [Reason and when this will be revisited]

ESKD Life-Plan

(Present the planned modality sequence with aligned access strategy. If Modality 2 or 3 is undetermined, document "not determined; will reassess by [timeframe or trigger].")

Modality 1 (Primary/Next)

• Modality and setting: [HD / PD / transplant / conservative management] — [home / in-center]
• Anticipated timeframe or trigger: [Timeframe or clinical trigger for initiation]
• Aligned access strategy: [Intended access type, site sequence, and bridging approach if needed; or PD catheter timing; or transplant vessel preservation plan]
• Rationale: [Brief justification based on comorbidities, anatomy, support system, prior failures]

Modality 2 (Anticipated Next)

• Modality and setting: [HD / PD / transplant / conservative management / not determined]
• Anticipated timeframe or trigger: [Timeframe or trigger for transition]
• Aligned access strategy: [Access plan for this modality]
• Rationale: [Brief justification]

Modality 3 (Contingency)

• Modality and setting: [HD / PD / transplant / conservative management / not determined]
• Anticipated timeframe or trigger: [Timeframe or trigger for transition]
• Aligned access strategy: [Access plan for this modality]
• Rationale: [Brief justification]

Access Needs Plan

Vessel Preservation

• Precautions: [Avoid PICC lines; avoid subclavian CVCs; minimize venipuncture in potential access arm(s)]
• Preferred venipuncture sites: [Sites and arm considerations if draws are needed]
• Existing devices threatening access: [Pacemaker/ICD leads; prior CVC sites; other devices]
• Communication plan: [EHR alerts placed; team notifications; patient wallet card/bracelet]

Access Creation Plan

• Intended access type: [AVF / AVG / endovascular AV access / tunneled CVC / PD catheter]
• Proposed site and laterality: [Anatomic site and side with justification] (Use distal-to-proximal logic when applicable.)
• Required pre-operative studies: [Vessel mapping ultrasound; venography if central stenosis suspected; cardiac evaluation if indicated]
• Target dates: Mapping: [Date] | Surgical/IR visit: [Date] | Access creation: [Date] | Expected usability: [Date or criteria]
• Bridging strategy if access not ready: [Bridge plan if needed]

Contingency Plan

• If AVF/AVG not usable by target date: [Evaluate for correctable lesion vs proceed to alternate access vs catheter bridge]
• If thrombosis occurs: [Urgent declot pathway and temporary dialysis access plan]
• If infection suspected: [Culture prior to antibiotics when feasible; empiric coverage; catheter management]
• [Other patient-specific contingencies]

Succession Plan

• Plan A (current): [Current planned access site]
• Plan B: [Next candidate access site and constraints]
• Plan C: [Subsequent candidate access site and constraints]
• What would exhaust each option: [Events or procedures that would preclude future options]

Access History

(Document all prior vascular accesses and PD catheters. If dates are unknown, document "approximate" and note plan to obtain records.)

• [Access type] — [Laterality] — [Location]: Created [Date] | Abandoned [Date] | Reason for failure: [non-maturation / stenosis / thrombosis / infection / steal / aneurysm / patient preference] | Interventions: [Number and type] | Complications: [Details]
• [Additional access entries as needed]
• Catheter history: [Prior CVC sites, durations, and indicators of central venous stenosis]
• Anticoagulation/antiplatelet context: [Agents, indications, relevance to bleeding/thrombosis risk]

Current Access Evaluation

Subjective

(Document patient and dialysis unit reports organized by complication domain.)

• Usability: [Cannulation difficulty, pain, infiltration, hematoma]
• Function: [Blood flow issues, pressure trends, recirculation, adequacy changes, alarms, clotting]
• Bleeding: [Prolonged post-needle bleeding or other concerns]
• Infection symptoms: [Fever/chills, exit-site drainage, redness, tenderness]
• Venous hypertension/central stenosis: [Arm/face/neck swelling, collateral veins]
• Ischemia/steal symptoms: [Coolness, numbness/tingling, pain during or between dialysis, wounds]
• Aneurysm concerns: [Rapid enlargement, skin thinning, ulceration]
• Heart failure symptoms: [Dyspnea, edema, orthopnea if access-related concern]

Objective Exam

(Use systematic "look, listen, feel" approach.)

• Inspection: [Erythema, edema, drainage, skin integrity, aneurysm characteristics]
• Palpation: [Thrill quality—continuous vs systolic-only; pulse character; tenderness]
• Auscultation: [Bruit character and changes along the circuit]
• Distal perfusion: [Pulses, capillary refill, temperature, sensorimotor findings]
• Limb edema and collaterals: [Presence and extent]
• CVC evaluation: [Exit site, tunnel, cuff position, dressing condition] (If applicable.)

Objective Data

• Dialysis session data: [Recent Qb trends, pressures, delivered dose, alarms, clotting] (Only include available data.)
• Imaging: [Ultrasound mapping with vessel diameters/depth; duplex or fistulogram findings; central venous evaluation] (If not performed, state "not performed" with reason.)
• Infection workup: [Blood cultures, exit-site cultures, relevant labs]
• Contrast considerations: [Risk/benefit and mitigation if residual kidney function present]

Assessment

(Provide a severity-ordered, problem-oriented synthesis. Use "suspected" vs "confirmed" language appropriately. Do not label problems as confirmed without diagnostic basis.)

[Problem 1 with suspected/confirmed status]

[Brief synthesis linking subjective and objective data to impression]

[Problem 2 with suspected/confirmed status]

[Brief synthesis] (Include additional problems as applicable.)

Plan

Timeline

• [Task] — [Target date] — [Responsible party]
• [Referrals placed: recipient, urgency, clinical question]
• [Studies ordered with timing]
• [Access creation target] | [Expected readiness] | [Catheter removal goal]
• [Follow-up appointment and pre-visit requirements]

Problem-Based Actions

• KRT trajectory and modality planning: [Transplant referral status; home dialysis training plan or reason not candidate]
• Suspected stenosis: [Clinical indicators; imaging plan and timeline]
• Thrombosis: [Declot pathway; dialysis bridge; post-procedure surveillance]
• Aneurysm: [Urgency based on skin risk; cannulation avoidance; referral if indicated]
• Steal/ischemia: [Severity; safety instructions; referral urgency]
• Suspected CVC infection: [Culture timing; empiric coverage; catheter management]
• CVC dysfunction: [Definition applied; troubleshooting; escalation pathway]
• Other problems: [Actions aligned to assessment]

Dialysis Unit Communication

• Cannulation status: [ready / maturing / do not cannulate]
• Cannulation method: [Rope-ladder / buttonhole / area rotation / ultrasound-guided]
• Do not cannulate segments: [Segment(s) to avoid and reason]
• Catheter care reminders: [Dressing protocol, locking solution, aseptic technique]

Medications

• Anticoagulant/antiplatelet peri-procedural plan: [Hold/continue instructions and responsible prescriber]
• Antibiotics: [Agent, route, duration; avoid vessel-damaging lines]
• Relevant allergies: [Antiseptics, contrast, antibiotics]

Patient Education

• Daily access self-check: [Look, listen, feel; what to report urgently]
• Catheter care behaviors: [Showering precautions, securement, infection prevention] (If applicable.)
• Emergency steps for aneurysm rupture: [Direct pressure; call emergency services]
• Vessel preservation behaviors: [Avoid BP cuffs/venipuncture on access arm]
• Materials provided: [Written materials; teach-back completed]

Follow-Up and Monitoring

• Life-plan review interval: [Annual minimum / sooner if changes]
• Access review interval: [Timing and modality]
• Return precautions: [Infection signs, worsening ischemia, new swelling, inability to dialyze, bleeding]

Acknowledgment

[Patient participation statement] (Document whether patient provided input, understands the plan, and agrees; or document if patient declined, was unavailable, or lacked capacity. State whether this is an initial plan, annual update, or revised plan.)