Document Code No.
CHS/BSN-CURR -RLEFORM-005a
Revision No. Effective Date Page No.
00 02.24.2023 1 of 2
Hemodialysis Treatment Form
Patient Machine No.: ___________________ Age: ____ Gender:_______Blood Type:_____ Height:
_____cm Nephrologist: ______________
Institution Assigned: ______________________ Dry Weight : _________kg Previous Post HD Weight:
___________kg Date: ________________
PRE HD POST HD DIALYSIS ANTICOAGULANT HEPA PROFILE
PARAMETER
BP: HR: BP: HR: UF GOAL: HEPARIN Hbsag:
RR: O2 SAT: RR: O2 SAT: Treatment Time: Bolus: HCV:
Weight: Weight: Dialysis Flow Rate: Anti HBs:
Rate:
Assessment Assessment Blood Flow Rate: NSS DIALYZER DETAILS
Flushing
Ambulatory Ambulatory K t/v: Volume: Dialyzer Type:
Wheelchair Wheelchair ISO UF: Frequency: Dialyzer Use:
Stretcher Stretcher Time : New
Neurologic Neurologic VASCULAR ACCESS
Alert Alert BLOOD Type and Size Cannulation
SPECIMEN
Conscious Conscious PRE HD AVF Gauge Arterial ____
# Venous____
Confuse Confuse AVG Gauge Arterial ____
# Venous____
Unconscious Unconscious POST HD Assessment of Access Site
Others: Others:
HGT Central Cath Location:
MONITORING
Integumentary Integumentary 1st hour Type: Heparin use
Good skin Good skin 2nd hour Dressing done by: Arterial:
turgor turgor
Pale Pale 3rd hour Venous:
Jaundice Jaundice 4th hour Assessment of CCD Site
Dry and flaky Dry and flaky
Edema Edema BLOOD TRANSFUSION RECORD
Others: Others: Time infuse Volume/Serial Expiration Date
/Component Number
Respiratory Respiratory
Dry cough Dry cough
Productive Productive Time ended Reaction Verified/Administered
cough cough by
Crackles/Rales Crackles/Rales
Pleural Pleural
Effusion Effusion
Others: Others:
MEDICATION RECORD
Signs of Bleeding Signs of Bleeding Drug name Dosage and Route Initial
Minimal Minimal
Moderate Moderate
severe severe
Others Others
Additional assessment noted (USE SEPARATE SHEET IF NECESSARY)
Document Code No.
CHS/BSN-CURR -RLEFORM-005a
Revision No. Effective Date Page No.
00 02.24.2023 2 of 2
HEMODIALYSIS MONITORING SHEET and NURSES NOTES
TIME BP HR BFR AP VP TMP FLUID UF VOL
TIME FOCUS CHARTING INITIAL
STUDENT-IN-CHARGE: ____________________________________________________________
CLINICAL INSTRUCTOR: ___________________________________________________________
DATE: _________________________________________________________________________
