Hemodialysis Communication Record 

Purpose: 

To ensure effective communication and documentation between the skilled nursing facility and the hemodialysis facility for residents receiving hemodialysis treatment. 

Procedure: 

1. Record Details: 

• Resident Information: 

• Resident Name: __________________________________________ 

• Age: ______________ 

• Date: ______________ 

• Athena Health Care Facility: 

• Facility Name: __________________________________________ 

• Unit: ______________ 

• Phone #: ______________ 

• Hemodialysis Facility: 

• Name: __________________________________________ 

• Date of Last Treatment: ______________ 

2. Vital Signs Pre-Treatment: 

• BP: ______________ 

• Temp: ______________ 

• Pulse: ______________ 

• Resp: ______________ 

3. Communication from the Skilled Nursing Facility: 

• Document any changes in the resident’s condition since the last hemodialysis treatment, including: 

• Changes in weight 

• Medications 

• Behavior 

• Appetite 

• Falls 

• Charge Nurse Signature: __________________________________________ 

4. Communication from the Hemodialysis Facility: 

• Vital Signs Post-Treatment: 

• BP: ______________ 

• Temp: ______________ 

• Pulse: ______________ 

• Resp: ______________ 

• Pre-Tx Weight: ______________ 

• Post-Tx Weight: ______________ 

• Lab Work Done: 

• Access Condition: 

• Communication/Recommendations: 

5. Compliance and Documentation: 

• Adhere to CMS guidelines and Requirements of Participation for Long-Term Care Facilities. 

• Ensure the Hemodialysis Communication Record is complete and accurate, documenting all necessary information for each treatment. 

• Regularly review and update communication protocols between the skilled nursing facility and the hemodialysis facility according to the latest clinical best practices and regulatory standards. 

• Provide training to staff on proper documentation and communication procedures to ensure resident safety and continuity of care. 

• Conduct regular audits to ensure compliance with this policy and address any gaps in practice or documentation. 

References: 

• Centers for Medicare & Medicaid Services (CMS). State Operations Manual (SOM), Appendix PP - Guidance to Surveyors for Long-Term Care Facilities. 

• CMS Requirements of Participation for Nursing Homes.