“Según la Fundación Mexicana del Riñón A.C. más de 100 mil personas padecen Insuficiencia Renal Crónica en México, con una tasa de crecimiento anual del 11%”.

En Dytsa nos interesa conocerte y programar su visita:

Le agradeceremos llenar el siguiente formulario en línea ó tambien puede enviarlo por Fax.

Fax (01 33) 3615 5540 con 3 líneas.
Lada Nacional sin Costo 01 800 723 9872
Lada Internacional sin Costo: 1 866 307 9179

Forum of ESRD Networks / The National Kidney Foundation
Uniform ESRD Transient Hemodialysis Form
PATIENT INFORMATION

Patience Name:

(first, last)
Date of Birth:
(dd/mm/yyyy)
Sex / Marital Status:
Parent or Legal Guardian (if minor):
Adress:
Phone (home):
Phone (work):
SSN#:
HIC#:
Date of first Dialysis:
ESRD Diagnosis:
(primary)
(secondary)
Treatment Dates requested:
(dd/mm - dd/mm)
Preferred Time:
REFERRING DIALYSIS UNIT INFORMATION

Referring Unit Name:


Phone:
Fax:

Contact Nurse:
Social Worker:
Primary Nephrologist:
Phone:
Fax:
Emergency Pt. Contact Name:
Relationship:
Phone (home):
Phone(work):
LOCAL RESIDENCE INFORMATION (transient city)

Local Adress or Hotel:

Phone:
Emergency Contact:
Relationship:
Phone:
Admitting Nephrologist:
Phone:
CURRENT TREATMENT ORDERS
 
Home:
In-Center Hemo:
Self Care:
Staff Assisted:
Dialyzer:
Reuse
(yes, no)
Blood Flow:
Dialyzate Flow:
Treatment Type:
Conventional:
High Flux:
High Efficiency:
Volumetric:
(yes, no)
Times Per Week:

Prescribed Time:

Dialyzate Rx:
K+
CA++
Dextrose
Sodium
Bicarb
Acetate
Sodium Modeling:
Dry Weight:
(kgs.)
(lbs.)
Heparinization Method:
Total Units:
If pump, DC:
hr / min pretreatment termination
 
VASCULAR ACCESS

Vascular Access:

Type:
Location:
Flow Direction:
Local Anesthetic:
(yes, no)
Usual Venous Pressure:
Diagram:
Other Special Cannulations Specifications:

i.e., needle gauge, self-cannulation

Vascular catheter special flush instructions:

 

PACIENT SPECIFIC INFORMATION
(synopsis of unique characteristics of patient's treatments)

Allergies:
Patient's trends and usual response to treatment:
Inter dialyctic wg gains:
kg.
B/P range:
Pre
Intradialyctic
Post
Usual B/P Support Methods:
Unusual reactions or needs:
Special needs or circunstances relative to transient visit:
 
INTRADIALYTIC MONITORING:if applicable, otherwise note "N/A"

Special Labs:

Blood glucose:
Intradialyctic treatments:
Dressings
O2
Other:
EPO:
(yes, no)
Units
SQ
IV
x's /week
Calcijex:
(yes, no) Mcg x's / week
Intradialyctic Meds: (i.e, infed):
Mobility:
Ambulatory
Non-Ambulatory
Ambulatory with assist
Special Dietary Considerations:
Intradialyctic Nutrition Orders:
Fluid Restriction:
 
ENCLOSURES: CHECK INDICATES INFORMATION SENT FROM HOME FACILITY
Standing Orders
Advance directive, if applicable
Problem list (last 6 months)
Current H&P (within 1 year)
Medication record (home and in-center)
Hemo last 3 treatment records
Most recent phsyco-social evaluation
Long-care term plan (current year)
Pacient care plan (most recent 6 months)
Most recent nutritional assesstment
Progress note (past 3 months to current):
MD
RN
RD
MSW
Diagnostic tests:
EKG
CXR (within 2 years)
Laboratory profile (within last 30 days)
HbsAg Status:
Positive
Negative
Date: (dd/mm/yyyy)
HbsAB:
Positive
Negative
Date: (dd/mm/yyyy)
Vacine Series Complete:
(yes, no)
Insurance information, carrier name & address current copies (front & back) of the following:
Medicare Card
Co-insurance card (s)
Other (specify):
 
   
TRANSPLANT LIST INFORMATION (if applicable) FOR SEASONAL PATIENTS ONLY
 
LRD
Cadaver
Transplant facility name and address:
Contact Person:
Phone:
   
SPECIAL INSTRUCTIONS

   
PATIENT IS NOT ACCEPTED UNTIL OFFICIAL NOTICE IS RECEIVED FROM RECEIVING UNIT
 
Signature (refferring unit person who completes the form):
Title:
Date:
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