HD-CL-006 · Hemodialysis Prescription & Monthly Review (UPDATED)

Hemodialysis Prescription, Documentation, and Monthly Review

Policy HD-CL-006 · Hemodialysis Unit

Effective June 25, 2026 Review June 25, 2027 Replaces all previous

1 Purpose

To standardize the process for nephrologist ordering, RN implementation, and interdisciplinary monthly review of the hemodialysis prescription to ensure adequate dialysis, volume control, electrolyte management, and patient safety per KDOQI 2015, KDIGO 2025, and MOH-Jordan Standards 2023.

2 Scope

Applies to all nephrologists, registered nurses, dialysis technicians, dietitians, and medical director responsible for prescribing, executing, or reviewing hemodialysis treatments.

3 Definitions

HD Prescription written MD order – renewed monthly Kt/V target ≥1.2 (≥1.4 recommended) URR target ≥65% Dry Weight normotension, no edema UFR ≤13 mL/kg/hr (KDOQI/KDIGO)

4 Policy Statement UPDATED

Update 1.1 KDIGO 2025 alignment & safety

MD: written Rx updated monthly. RN: verify Rx before each treatment. No treatment without order. Monthly review required.

KDIGO 2025 integration: • UFR ≤13 mL/kg/hr explicitly enforced; if >13, MD must document clinical justification and mitigation plan. • Individualized Kt/V target based on muscle mass, residual renal function, and patient goals. • Shared decision-making with patient documented.

Rationale: KDIGO 2025 emphasizes personalized targets, UFR safety, and patient-centered care. MOH 2023 requires explicit UFR documentation.

Update 1.2 "Standard" orders prohibition

"Standard" or "Routine" orders prohibited. Each parameter must be individualized.

Explicit prohibition: Orders such as "standard HD," "routine Kt/V," or "as per protocol" are NOT acceptable. Every parameter (duration, Qb, Qd, dialysate composition, UFR, heparin, anemia/iron/antibiotic doses) must be individually ordered and signed.

Rationale: JCI and MOH audits consistently cite generic orders; individualization reduces medication errors and improves outcomes.

5 Procedure UPDATED

A. Components of the Hemodialysis Prescription UPDATED

Update 2.1 Expanded prescription elements

16 parameters listed. Prescription valid 30 days.

Added parameters: • UFR Limit (must be ≤13; if >13, justification and mitigation plan) • Dialysate Magnesium (1.0-1.5 mEq/L) • Dialysate Glucose (if used) • Anticoagulation type (heparin, citrate, or none) • Access-specific notes (needle gauge, direction, buttonhole vs rope ladder).

Rationale: KDIGO 2025 recommends magnesium and glucose consideration; access-specific notes reduce cannulation errors.

Parameter	Standard Range	Individualization Required	RN Verification Before Start
Frequency	3x/week	2x-6x/week per residual function	Matches schedule
Duration	3.5-4.5 hours	Extended if high UFR or poor clearance	Time matches order
Blood Flow Qb	300-450 mL/min	Based on access, cardiac status. Min 200 for CVC	Can access deliver Qb?
Dialysate Flow Qd	500-800 mL/min	1.5-2x Qb typically. High-efficiency = 800	Machine set correctly
Dialyzer	High-flux preferred	Surface area per patient size	Matches order + not expired
Dialysate Na	138-140 mEq/L	136-140. Individualize for IDH/HTN	Check concentrate
Dialysate K	2 or 3 mEq/L	1-4 mEq/L based on pre-K. 2K default	Check concentrate
Dialysate Ca	2.5 mEq/L	2.0-3.0 per Ca/Phos/PTH	Check concentrate
Dialysate Bicarb	32-38 mEq/L	Based on acid-base. Default 35	Check concentrate
Dialysate Mg NEW	1.0-1.5 mEq/L	Based on serum Mg	Check concentrate
Dialysate Temp	36.0-36.5°C	35.5°C for IDH-prone if ordered	Verify machine temp
Dry Weight	Assessed monthly	Adjust for edema, BP, hospitalizations	Pre-weight - UF goal = Dry Wt?
UFR Limit NEW	≤13 mL/kg/hr	If >13, document justification + mitigation plan	RN to calculate. If >13, call MD
Heparin	Load 1000-5000u, hourly 500-2000u/hr	Hold for bleeding, pre-op, platelets <50k	Double-check dose
ESA	Per anemia protocol	Hold if Hb >11.5 or BP >180/100	Check Hb + BP first
IV Iron	Per iron protocol	Hold if infection, ferritin >800	Check labs + temp
Antibiotics	Per culture	Dose post-HD typically	Give after HD unless ordered
Access Notes NEW	Per access type	Needle gauge, direction, buttonhole vs rope ladder	Matches order

B. RN Pre-Treatment Verification UPDATED

Update 2.2 UFR calculation & lab alerts

UFR calculation: if >13, call MD. Lab alerts: K >6.0, Hb <7 or >12, Ca >10.2.

UFR: calculate using actual post-weight from previous session when available. If >13, call MD and document justification in chart. Lab alerts expanded: K >6.0, Hb <7 or >12, Ca >10.2, Phos >7.0, PTH >800 – call MD before start.

Rationale: Using actual post-weight improves UFR accuracy; expanded lab alerts align with KDIGO 2025 mineral and bone disorder thresholds.

Pre-Treatment Checklist (HD-CL-006-F2):

Current MD order (≤30 days) with all parameters
2 patient identifiers verified
Access assessment (Look, Listen, Feel) documented
UFR calculated: ≤13 mL/kg/hr (or MD justification documented)
Lab alerts reviewed (K, Hb, Ca, Phos, PTH)
Machine dialysate temp, conductivity, pH within limits
Alarms tested

If ANY check fails: DO NOT START. Notify in-charge RN + MD. Document.

C. Monthly Interdisciplinary Review UPDATED

Update 2.3 Expanded review elements

Adequacy, volume, access, anemia, MBD, nutrition, medications, hospitalizations, output.

Added elements: • Patient-reported outcomes (symptoms, quality of life, IDH episodes) • UFR trend – if consistently >13, documented plan to reduce • Medication reconciliation with patient home meds • Advance care planning discussion documented if appropriate.

Rationale: KDIGO 2025 emphasizes patient-reported outcomes and advance care planning; MOH 2023 requires medication reconciliation.

Monthly Review (by 15th of each month): Nephrologist, RN in-charge, dietitian, social worker. Review 100% of patients using HD-CL-006-F3.

Required elements: Adequacy (last 3 Kt/V/URR), Volume/IDH, Access, Anemia, MBD, Nutrition, Medications, Hospitalizations, UFR trend, Patient-reported outcomes, Advance care planning.

Output: New signed prescription for next month. Copy to chart + patient takes home summary.

D. Prescription Changes – Mid‑Month

Who Can Change: Nephrologist only. Verbal order in emergency, signed 24h.

Triggers for Change: Hospitalization, access intervention, SBP <90 recurring, Hb <8 or >12, K >6.0, fluid overload admission, UFR >13 consistently.

RN Role: If RN identifies need for change, call MD and document. RN cannot change without order.

7 Staff Competency UPDATED

Update 3.1 UFR competency & MD audits

RN: pass med calc test including UFR 100% accuracy. New RN: 90-day co-sign. Medical Director audits 10% monthly.

RN: UFR calculation test 100% accuracy required annually. New RN: cannot verify prescription independently for 90 days; co-sign with preceptor. Medical Director: audits 10% of monthly reviews for completeness and KDOQI/KDIGO compliance; findings reported to QAPI.

Rationale: 100% accuracy for UFR prevents fluid overload; MD audit ensures accountability.

8 Quality Monitoring – QAPI Indicators UPDATED

Update 4.1 New quality metrics

% current Rx 100%, Kt/V ≥1.2 >95%, UFR ≤13 >90%, Rx reviewed 100%, starts without Rx check 0, IDH episodes correlated.

Add: • % prescriptions with UFR justification documented (if >13) – target 100% • % patients with documented shared decision-making – target 100% • % monthly reviews completed by 15th – target 100% • % patients with advance care planning documented – target >50%.

Rationale: KDIGO 2025 emphasizes shared decision-making and advance care planning; UFR justification is a regulatory requirement.

9 References UPDATED

Update 5.1 Updated reference list

KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update. Am J Kidney Dis. 2015;66(5).
KDIGO 2025 Clinical Practice Guideline for Dialysis Initiation, Modality Choice, and Prescription: DRAFT (with 2025 commentary on UFR and shared decision-making).
Ministry of Health – Hashemite Kingdom of Jordan. Standards for Hemodialysis Units, 2023. Section 7: Clinical Care.
Flythe JE, et al. Rapid fluid removal during dialysis is associated with cardiovascular morbidity. Kidney Int. 2011;79(2).
JCI Accreditation Standards for Hospitals, 8th Edition. Assessment of Patients AOP.
MOH-Jordan Prescription Audit Standards, 2024.

⏺ Summary of key updates

Section	Update	Clinical rationale
4. Policy	KDIGO 2025 alignment: UFR ≤13 enforced with justification; shared decision-making; individualized Kt/V targets	KDIGO 2025 emphasis on safety and patient-centered care; MOH 2023 requires UFR documentation
5. Procedure (A)	Added dialysate Mg, glucose, UFR limit, anticoagulation type, access-specific notes to prescription	KDIGO 2025 recommends Mg/glucose; access-specific notes reduce errors
5. Procedure (B)	UFR using actual post-weight; lab alerts expanded (Phos >7.0, PTH >800)	Improved UFR accuracy; KDIGO 2025 MBD thresholds
5. Procedure (C)	Added patient-reported outcomes, UFR trend, medication reconciliation, advance care planning to monthly review	KDIGO 2025; MOH 2023 medication reconciliation requirement
7. Competency	RN UFR test 100% accuracy; Medical Director audits 10% of reviews	Prevents fluid overload; ensures accountability
8. QAPI	New KPIs: UFR justification documentation, shared decision-making, timely monthly reviews, advance care planning	KDIGO 2025 and MOH regulatory requirements

Policy HD‑CL‑006 · Proposed updates June 26, 2026 All changes reviewed against KDOQI 2015, KDIGO 2025, MOH‑Jordan 2023, and JCI 8th Edition.

Hemodialysis Prescription Documentation And Monthly Review · Version 2026-06-27 · Hemodialysis Unit

📋 Back to All Policies · 🖨️ Print This Page

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