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

Hemodialysis Orders 

Effective Date: [Original NPP Date] 
Revised Date: [Current Date] 

Policy Statement: 

Orders for hemodialysis for residents must be accurately documented and placed on physician order forms/Electronic Charting System (ECS) in compliance with the CMS Requirements of Participation and the State Operations Manual (SOM) for Long-Term Care Facilities (LTC). 

Hemodialysis Orders: 

• Hemodialysis Location: 

Send resident to hemodialysis at (location): __________________________________________ 

• Hemodialysis Schedule: 

Hemodialysis will be conducted 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 

• Note: No BP or venipuncture is to be performed on the access arm. 

• Fluid Restriction: 

Fluid Restriction: ____________ cc/24 hour. Allocation of fluids is as follows: 

• Nursing: 

• _____________ cc per 24 hours or 

• _____________ cc 7-3 shift, 

• _____________ cc 3-11 shift, 

• _____________ cc 11-7 shift. 

• Dietary: 

• _____________ cc per 24 hours. 

• Weights: 

• o Daily (QD) 

• o Weekly (Q Week) 

• o Biweekly (Q O Week) 

• o Monthly (Q Month) 

Signatures: 

MD Signature Date 

Transcribed By Date 

References: 

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

• CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines]