Genitourinary Renal

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Trace DC51-13

DiraChart Clinical Reference
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1. Purpose and clinical relevance

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Daily-note bank — routine skilled days

Scenario

Model daily note (edit to the shift)

ESRD, non-dialysis day

AV fistula with palpable thrill/audible bruit, access limb protected, weight/volume at the dry-weight target, no uremic symptoms, on the renal diet and binder per order. Skilled access and volume assessment and dialysis coordination required daily; supports the Section O dialysis item.

AKI recovery

I&O balanced, urine output improving, weight stable, no edema, electrolytes trending to normal, tolerating the renal diet. Skilled observation for fluid-electrolyte change required; supports Section I.

Post-dialysis assessment

Post-hemodialysis: tolerated treatment, no hypotension or cramping, access site without bleeding, weight at target, oriented. Skilled post-dialysis observation and access assessment required; supports the Section O dialysis item.

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