Assess renal, fluid, and electrolyte status and document the skilled judgment:
Intake and output and daily weight against the ordered parameters; volume status (edema, lung sounds, blood pressure) and any orthostatic change.
For a dialysis access: the AV fistula/graft (thrill and bruit) or the catheter site, and the protection of the access limb; the dialysis schedule and the post-dialysis status.
Signs of uremia or fluid-electrolyte disturbance (confusion, nausea, weakness, arrhythmia) and the renal-diet and medication response.
MDS-supportive data
Dialysis is coded in MDS Section O0110; renal-related medications in Section N; the renal diet in Section K; the renal diagnosis in Section I. The record must document the dialysis, intake/output/weight, and the assessment so the MDS is supported.
