Hemodialysis Orders 

Purpose: 

To provide clear and standardized orders for residents requiring hemodialysis, ensuring proper documentation and adherence to treatment protocols. 

Procedure: 

Hemodialysis Orders (To be placed on physician order forms/ECS) 

Resident Information: 

• Resident Name: __________________________________________ 

• Age: ______________ 

• Date: ______________ 

Hemodialysis Facility: 

• Send resident to hemodialysis at (location): __________________________________________ 

Schedule: 

• On the following days: ___________________________________________________________ 

Hemodialysis Access Device/Location: 

• Venous Catheter: 

• Location: 

• o Right Chest Wall 

• o Left Chest Wall 

• o Other: ____________ 

• AV Fistula: 

• Location: 

• o Right Arm 

• o Left Arm 

Special Instructions: 

• No BP or venipuncture on the access arm. 

Fluid Restriction: 

• ______________ cc/24 hours. Allocation of fluids as follows: 

• Nursing: ______________ per 24 hours or ______________ cc 7-3, ______________ cc 3-11, ______________ cc 11-7 

• Dietary: ______________ per 24 hours 

Weights: 

• o QD 

• o Q Week 

• o Q O Week 

• o Q Month 

Physician Authorization: 

• MD Signature 

• Date 

Transcription: 

• Transcribed By 

• Date 

Compliance and Documentation: 

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

• Document the orders, including the resident’s response and any observations, in their medical record. 

• Note any abnormalities or difficulties encountered during the procedure. 

• Regularly review and update techniques for documenting hemodialysis orders according to the latest clinical best practices and regulatory standards. 

• Provide training to staff on proper documentation procedures to ensure resident safety and treatment accuracy. 

• 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.