HD-CL-006-F3 · Monthly Interdisciplinary Review (UPDATED)

Monthly Interdisciplinary Review Form

Form HD-CL-006-F3 · Hemodialysis Unit – [Hospital Name]
Month/Year: _________ Meeting Date: _________
📋 Updated June 26, 2026 KDIGO 2025 aligned · UFR trend · patient-reported outcomes · advance care planning
PROPOSED UPDATES
Attendees – Required Signatures
A Dialysis Adequacy – KDOQI Target spKt/V ≥1.2
hrs ×/week mL/min
1. 2. 3.
1. % 2. % 3. % %
B Volume Status – KDOQI UFR ≤13 mL/kg/hr UPDATED
kg
kg % of EDW
mmHg mmHg
times last month (SBP <90 or symptoms requiring NS bolus)
times last month
kg
Last 3 sessions: , , mL/kg/hr
KDIGO 2025 requires trending and action plan
C Vascular Access – KDOQI Fistula First UPDATED
mL/min
Avg last month mmHg at Qb 200
CVC Only Section – MOH Required if >10% unit CVC rate
D Anemia Management – KDOQI Hb 10-11.5 g/dL
g/dL
% ng/mL
units mcg mcg
mg
E Mineral & Bone Disorder – KDOQI
mg/dL mg/dL pg/mL
F Nutrition – KDOQI Albumin ≥4.0 g/dL
g/dL g/kg/day
kg kg
G Medication Review
H Psychosocial & Quality of Life UPDATED
KDIGO 2025 requirement
KDIGO 2025 & MOH 2023
I Hospitalizations & Adverse Events
J New HD Prescription Orders for Next Month UPDATED
Must complete HD-CL-006-F1 based on this review
≤ mL/kg/hr kg
Team Consensus & Sign-Off

The interdisciplinary team has reviewed all data and agrees with the plan above. New prescription HD-CL-006-F1 completed.

Nephrologist Signature: Date/Time:
RN In-Charge Signature: Date/Time:
Form HD-CL-006-F3 · Updated June 26, 2026 KDIGO 2025 · KDOQI 2015 · MOH-Jordan 2023 aligned
This review must be completed monthly for 100% of patients by the 15th of each month. New prescription must be signed and placed in chart.

HD-CL-006-F3 · Version 2026-06-27 · Hemodialysis Unit

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Aligned with KDOQI, AAMI/ISO, CDC, MOH-Jordan 2023, JCI 8th Ed.

✍️ Author: Ahmed Mohmad Rashyd Musleh Registered Staff Nurse