Document the dialysis-specific skilled surveillance and management each day:
The dialysis modality and schedule, the pre- and post-dialysis status (weight versus the dry-weight target, blood pressure, and symptoms), and communication with the dialysis unit.
The access: for an AV fistula/graft, the thrill and bruit and limb protection (no BP/venipuncture); for a hemodialysis catheter or a peritoneal-dialysis catheter, the site and dressing; for PD, the exchanges, dwell, and effluent clarity (a cloudy effluent suggests peritonitis).
The fluid-electrolyte balance between sessions (edema, lung sounds, potassium/phosphate context) and the renal diet, medication, and phosphate-binder adherence.
MDS-supportive data
Dialysis is coded in MDS Section O0110, medications in Section N, the renal diet in Section K, and ESRD in Section I. The record must document the dialysis coordination, the access assessment, and the fluid-electrolyte status so the MDS is supported.
