Holiday dialysis: medical records

Patient surname

Patient first name

E-mail

Date of birth

Renal disease

Date of first haemodialysis

Patient profile

Type of haemodialysis

Transplant candidate

Parameters for dialysis treatment

Number of dialysis sessions/week

Treatment duration

Dry weight

Blood flow rate (QB)

Dialysate flow rate (QD)

Type of dialysis treatment

Ultra-filtration maximum

Average weight gain between dialysis treatments

Sodium profile

UF profile

Recent problems/complications during dialysis treatments

Important comments in relation to dialysis treatment

Type of artificial kidney

Naam

Membrane

Surface area

Sterilisation

Dialysate composition

Sodium

Potassium

Calcium

Bicarbonate

Magnesium

Glucose

Temperature

Anticoagulants

Type

If Heparin, also enter initial and continual doses

Heparin initial dose

Heparin continual dose

Vascular access: (one or both; alternatively, select ‘not applicable’)

AV fistula

Catheter brand name

Localisation

Catheter lock with

Arterial priming volume

Venous priming volume

Allergy

Medication received during dialysis

Erythropoietin (= EPO) (cfr Hg)

Iron supplement

Other

Blood-borne infection serological results (max. 1 month old)

HIV

Result + date

Hep B SAg

Result + date

Hep B SAb

Result + date

Most recent vaccination

Hep C Ab

Result + date

Blood type

Other results

MRSA

Result + date

CPE

Result + date

Lab results

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Bacteriological results

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Medical report

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Home medicines

Ik ga akkoord met de gebruiksvoorwaarden en de privacyverklaring.

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