Patient Name:

MRN:

DOB:

Diagnosis: ESRD / Other:

Primary Nephrologist: Dr.

A Dialysis Parameters

Frequency: 1x/week 2x/week 3x/week Other:

Duration: hours minutes per session

Blood Flow Rate Qb: mL/min Min: Max:

Dialysate Flow Rate Qd: 500 mL/min 800 mL/min Other: mL/min

Dialyzer Type: Surface Area: m²

High-Flux Low-Flux

Dialysis Solution/Concentrate:

B Dialysate Composition

7. Sodium Na: mEq/L

Standard Profile:

8. Potassium K: 1K 2K 3K 4K mEq/L Variable per K level

9. Calcium Ca: 2.0 2.5 3.0 mEq/L

10. Bicarbonate: mEq/L

Standard 35 Other:

11. Temperature: °C

Standard 36.5°C Cooled 35.5°C for IDH

11a. Magnesium Mg NEW: mEq/L

1.0 1.5 Other:

KDIGO 2025 recommends Mg 1.0-1.5 mEq/L

C Volume & Anticoagulation

12. Estimated Dry Weight EDW: kg Reassess monthly or with clinical change

13. UFR Limit UPDATED: ≤13 mL/kg/hr (KDOQI/KDIGO) Other: mL/kg/hr

Justification if >13:

Mandatory MD justification if UFR >13

14. Heparin Protocol:

Loading Dose: units

None

Hourly Rate: units/hr

None

Stop 30min before end

Hold if: Bleeding, platelets <50k, pre-op, INR >2.0

No Heparin: Use saline flush protocol

D Vascular Access UPDATED

15. Access Type: AVF AVG Tunneled CVC Non-tunneled CVC

16. Location: L FA R FA L UA R UA L IJ R IJ Femoral

18. Access Orders: Rope Ladder Buttonhole (competency + order required) CVC per protocol

Special Instructions:

Access-specific notes NEW:

Direction, cannulation site preference, ultrasound guidance if needed

E Medications During Dialysis UPDATED

19. ESA: Epogen units Aranesp mcg Mircera mcg

Frequency:

Give: Last hour Post-HD

Hold if: Hb >11.5 g/dL or BP >180/100 or recent MI/stroke

20. IV Iron: Iron Sucrose mg Ferric Carboxymaltose mg

Frequency:

Hold if: Active infection, Ferritin >800, TSAT >50%

Test dose required for 1st dose (25mg over 5min, epinephrine at bedside)

21. Vitamin D: Calcitriol mcg Doxercalciferol mcg

Frequency:

Hold if: Ca >10.2 mg/dL or Phos >5.5 mg/dL

22. Antibiotics:

Give Post-HD

Other timing:

23. Other Meds:

F Special Instructions UPDATED

24. Blood Pressure Parameters:

Hold HD if: SBP > / < mmHg DBP > / < mmHg

Notify MD if: SBP <100 or >180 mmHg

25. Target Kt/V: ≥1.2 per session Other:

27. Diet During HD: NPO Small snack only No restriction

28. Other Orders:

28a. Shared decision-making documented NEW: Patient goals, preferences, and risks discussed. (date)

KDIGO 2025 requirement

G Monthly Review & Goals UPDATED

29. Last Month Kt/V: URR: % Avg IDWG: % IDH Episodes:

30. Access Issues:

31. Changes from Last Month:

32. UFR Trend NEW: Last 3 sessions: , , mL/kg/hr Plan if >13:

33. Advance Care Planning NEW: Discussed Documented in chart Not applicable

Physician Certification

I certify that I have reviewed the patient's clinical status, labs, and treatment data, and this prescription is individualized and medically necessary.

Nephrologist Signature: Date: Time:

Print Name: Stamp:

Orders Received & Verified By RN: Date/Time:

Hemodialysis Prescription Form