Form Cms-820 - In-Center Hemodialysis (Hd) Clinical Performance Measures Data Collection - 2005 Page 3

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IN-CENTER HEMODIALYSIS (HD) CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 (CONTINUED)
19.
SERUM ALBUMIN: Enter the 1st pre-dialysis serum albumin obtained for each month: OCT, NOV and DEC 2004. Include
the date the serum albumin was drawn. Enter NF/NP if the lab value cannot be located. Check the method used (BCG brom-cresol
green or BCP/bromcresol purple) by the lab to determine serum albumin. If lab method unknown, please call lab to find out.
OCT 2004
NOV 2004
DEC 2004
A. 1st pre-dialysis serum albumin of the month:
______ . ______ g/dL
______ . ______ g/dL
______ . ______ g/dL
Date: ____/____/_____
Date: ____/____/_____
Date: ____/____/_____
B. Check lab method used:
BCG = bromcresol green;
BCG
BCP
BCG
BCP
BCG
BCP
BCP = bromcresol purple
20. ADEQUACY: Enter the information requested below for the dialysis session when the 1st labs of the month were drawn
and used to measure adequacy for each month: OCT, NOV, DEC 2004. Include the date the labs were drawn. Enter NF/NP if
the information cannot be located.
OCT 2004
NOV 2004
DEC 2004
A. How many times per week was this patient
prescribed to receive dialysis during the week
_______times per week _______times per week
_______times per week
prior to when the pre and post BUNs were drawn?
B. 1st recorded URR of the month:
_____ _____ . _____% _____ _____ . _____%
_____ _____ . _____%
Date: ____/____/_____
Date: ____/____/_____
Date: ____/____/_____
C. 1st recorded single-pool Kt/V of the month:
_______ . _____ _____ _______ . _____ _____ _______ . _____ _____
Date: ____/____/_____
Date: ____/____/_____
Date: ____/____/_____
D. Method used to calculate the single-pool Kt/V
in 20C:
Urea Kinetic Modeling
Urea Kinetic Modeling
Urea Kinetic Modeling
(If unknown, please ask Medical Director)
Daugirdas II
Daugirdas II
Daugirdas II
Depner
Depner
Depner
Derived from URR
Derived from URR
Derived from URR
based on no pt. wts.
based on no pt. wts.
based on no pt. wts.
Other ____________
Other ____________
Other ___________
E. Was residual renal function used to calculate
Yes
No
Yes
No
Yes
No
the single-pool Kt/V in 20C on this patient?
Unknown
Unknown
Unknown
F.
1st pre-dialysis BUN value of the month:
__________ mg/dL
__________ mg/dL
__________ mg/dL
Date: ____/____/_____
Date: ____/____/_____
Date: ____/____/_____
G. 1st post-dialysis BUN value of the month:
__________ mg/dL
__________ mg/dL
__________ mg/dL
(both the pre & post dialysis BUN must be
Date: ____/____/_____
Date: ____/____/_____
Date: ____/____/_____
drawn on the same day)
H. Pre- & Post-dialysis weight at session when
Pre: _______.___ lbs/kgs Pre: ______.___ lbs/kgs
Pre: ______.___ lbs/kgs
BUNs above drawn: (Circle either lbs or kgs)
Post: _______.___lbs/kgs Post: ______.___ lbs/kgs Post:______.___ lbs/kgs
I.
Actual DELIVERED time on dialysis at session
when BUNs above drawn:
_____hrs ____ ____ min _____hrs ____ ____ min _____hrs ____ ____ min
J.
Delivered blood pump flow rate (BFR) @ 60
____ ___ ___ mL/min
____ ___ ___ mL/min
____ ___ ___ mL/min
minutes after start of dialysis session or average
60 min. after start of
60 min. after start of
60 min. after start of
delivered BFR when BUNs above drawn:
dialysis
dialysis
dialysis
average delivered BFR
average delivered BFR
average delivered BFR
K. Code for dialyzer used for dialysis session
when BUNs above drawn: (see chart)
_________________
_________________
_________________
CMS – 820 (Rev.1/27/05)

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