1
min read
A- A+
read

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

Nursing Administrative Manual

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] 

Tags
hemodialysis orders
Long-Term Care
Venous Catheter
AV Fistula
Fluid Restriction
nursing home policy
CMS compliance
SOM Guidelines
Electronic Charting System
Physician Orders
Section D. Nursing Administration Manual
Feedback Form

Post Category

Post Category
Nursing Administrative Manual

YouTube Videos'