Hemodialysis Communication Record

Hemodialysis Communication Record 

Policy 
To ensure seamless communication between the Skilled Nursing Facility (SNF) and the Hemodialysis Facility regarding resident care and condition, enhancing the continuity and quality of care for residents undergoing hemodialysis. 

Procedure 

1. Resident Information: 

• Resident Name: ____________________________________ 

• Age: _______ 

• Date: ___________ 

2. Facility Information: 

• Athena Health Care Facility: _________________________ 

• Unit: _______________ 

• Phone #: _______________ 

3. Hemodialysis Facility Information: 

• Hemodialysis Facility: ___________________________ 

• Date of Last Treatment: _______________ 

4. Vital Signs (To be completed by SNF): 

• BP: ______ 

• Temp: ______ 

• Pulse: ______ 

• Resp: ______ 

5. Communication from Skilled Nursing Facility: 

• Document any changes in condition from the last hemodialysis treatment (e.g., changes in weight, medications, behavior, appetite, falls). 

• Charge Nurse Signature: ______________________________ 

6. Communication from Hemodialysis Facility: 

• Vital Signs: 

• BP: ______ 

• Temp: ______ 

• Pulse: ______ 

• Resp: ______ 

• Pre-Tx Weight: ______ 

• Post-Tx Weight: ______ 

7. Lab Work Done: 

• Document any lab work performed during the hemodialysis session. 

• Lab Results: ______________________________________ 

8. Access Condition: 

• Document the condition of the hemodialysis access site. 

• Access Condition: ___________________________________ 

9. Communication/Recommendations: 

• Provide any additional communication or recommendations from the Hemodialysis Facility to the SNF. 

• Recommendations: ___________________________________ 

Documentation and Review: 

• Ensure that all information is accurately documented on the Hemodialysis Communication Record. 

• The completed form must be reviewed by the Charge Nurse upon the resident's return from the hemodialysis session. 

• Any significant issues or recommendations should be communicated to the physician, responsible party, and other members of the Interdisciplinary Team as necessary. 

References: 

• Centers for Medicare & Medicaid Services (CMS), State Operations Manual (SOM) 

• Requirements of Participation for Nursing Homes, CMS