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PERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 (CONTINUED)

21. PD ADEQUACY: The following data are requested for the

22. PERITONEAL DIALYSIS PRESCRIPTION: For the

FIRST PD ADEQUACY determination during the months OCTO-

following questions – record the PD prescription in effect at the

BER 2004 through MARCH 2005. Starting with the first adequacy

time the adequacy measures/results recorded in Question 21 were

measurement in these months, enter the adequacy measurements/

performed. Please read instructions on Page 6 before completing

results listed below that were obtained. (Please DO NOT record

this section. Enter NF/NP if information cannot be located.

more than one adequacy measurement done for any one month.)

Please read instructions on Pages 5 and 6 before completing this

section. Enter NF/NP if information cannot be located.

Prescription at the time

21.

Was PD adequacy measurement done

Yes

adequacy was measured

during OCT 2004-MAR 2005?

Unknown

in 21A

21A. Date of FIRST PD adequacy measure-

___ / ___ / _____

22A. CAPD PRESCRIPTION

ment between 10-1-2004 to 3-31-2005

(mm) (dd) (yyyy)

(this includes patients with one

overnight exchange using an

21B. Patient’s dialysis modality when

CAPD

Cycler

assist device)

adequacy measures were performed

(See definitions in instructions on p. 5)

1. Number of dialysis days per

_____________

week

(# days)

21C. Patient’s weight at the time of this

2. Total dialysate volume

adequacy assessment (abdomen

___ ___ ___ ___ ___

infused per 24 hours

empty) (Circle lbs or kgs)

______ . ___ lbs /kgs

mL/24 hrs

3. Total number of exchanges

21D. Weekly Kt/V

per 24 hours (including

_____________

urea

(dialysate and urine clearance)

____

_____ _____

overnight exchange)

(# exchanges)

21E. Method by which V above was

%BW

Hume

22B. CYCLER

PRESCRIPTION

calculated: Check one. (If unknown

Watson

1. Number of dialysis days per

_____________

please call lab.)

Other _________

week

(# days)

2. Total dialysate volume infused

___ ___ ___ ___ ___

21F. Weekly Creatinine Clearance

per 24 hours

mL/24 hrs

(dialysate and urine clearance)

__ __ __

__ L/wk

3. Total dialysis time

a. Total nighttime dialysis time

______hrs _______min

21G. Is this Creatinine Clearance

b. Total daytime dialysis time

corrected for body surface area,

Yes

______hrs _______min

c. Total amount of time the

using standard methods? (See

Unknown

patient is dry during

instructions on page 6)

24 hours

______hrs _______min

(Note: 3a+b+c = 24 hours)

21H. 24 hr DIALYSATE volume

(prescribed and ultrafiltration)

___ ___ ___ ___ ___mL

4. Nighttime Prescription

(excluding last bag fill)

21I.

24 hr DIALYSATE urea nitrogen:

___ ___ ___

___ mg/dL

___ ___ ___ ___

a. Volume of a single

mL/exchange

nighttime exchange

21J. 24 hr DIALYSATE creatinine:

___ ___

___ mg/dL

b. Number of dialysis

_____________

exchanges during the

(#/nighttime)

21K. 24 hr URINE volume:

nighttime

(If 24 hr urine was not located

___ ___ ___ ___ mL

5. Daytime Prescription

check NF/NP.)

NF/NP

(including last bag fill)

a. Volume of a single

___ ___ ___ ___

21L. 24 hr URINE urea nitrogen:

___ ___ ___

___ mg/dL

daytime exchange

mL/exchange

b. Number of dialysis

21M. 24 hr URINE creatinine:

___ ___ ___

___ mg/dL

exchanges during the

_____________

daytime

(#/daytime)

21N. SERUM BUN at the time this

PD adequacy assessment was done

___ ___ ___ mg/dL

6. Does the cycler prescription

21O. SERUM creatinine at the time this

described above include

PD adequacy assessment was done

___ ___

___ mg/dL

TIDAL dialysis?

Yes

Unknown

21P.1. Most recent 4 hour dialysate/plasma

22C. Based on the adequacy

creatinine ratio (D/P Cr) from a

____

_____ _____

result from questions 21A-O,

peritoneal equilibration test (PET).

2. Date of most recent D/P Cr

____ / ____ / _____

1. Was the collection repeated?

Yes

Unknown

(mm)

(dd)

(yyyy)

Yes

Unknown

2. Was the prescription changed?

CMS – 821 (Rev.1/20/05)

Form Cms-821 - Peritoneal Dialysis Clinical Performance Measures Data Collection - 2005 Page 3

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