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PERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FOR 2005: (CONTINUED)

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

Enter NF/NP if information cannot be located.

SECOND PD ADEQUACY determination during the months

24. PERITONEAL DIALYSIS PRESCRIPTION: For the

NOVEMBER 2004 through MARCH 2005. Starting with the second

following questions – record the PD prescription in effect at the

adequacy measurement in these months, enter the adequacy mea-

time the adequacy measures/results recorded in Question 23 were

surements/results listed below that were obtained. (Please DO NOT

performed. Please read instructions on Page 6 before completing

record more than one adequacy measurement done for any one

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

month.) Please read instructions on Page 6 before completing this

section.

23.

Was second PD adequacy measure-

Yes

Prescription at the time

ment done during 11-1-2004 to

Unknown

adequacy was measured

3-31-2005?

in 23A

24A. CAPD PRESCRIPTION

23A. Date of SECOND PD adequacy

___ / ___ / _____

(this includes patients with one

measurement between 11-1-2004 to

(mm) (dd) (yyyy)

overnight exchange using an

3-31-2005

assist device)

_______

1. Number of dialysis days per

23B. Patient’s dialysis modality when

CAPD

Cycler

(# days)

week

adequacy measures were performed

(See definitions in instructions on p. 5)

2. Total dialysate volume

___ ___ ___ ___ ___

infused per 24 hours

23C. Patient’s weight at the time of this

mL/24 hrs

adequacy assessment (abdomen

3. Total number of exchanges

empty) (Circle lbs or kgs)

_______.____ lbs /kgs

_____________

per 24 hours (including

(# exchanges)

overnight exchange)

23D. Weekly Kt/V

urea

24B. CYCLER

(dialysate and urine clearance)

____

_____ _____

PRESCRIPTION

1. Number of dialysis days per

23E. Method by which V above was

%BW

Hume

_______

week

calculated: Check one. (If unknown

Watson

(# days)

please call lab)

Other ___________

2. Total dialysate volume infused

___ ___ ___ ___ ___

per 24 hours

mL/24 hrs

23F. Weekly Creatinine Clearance

3. Total dialysis time

(dialysate and urine clearance)

__ __ __

__ L/wk

_____hrs ______min

a. Total nighttime dialysis time

b. Total daytime dialysis time

23G. Is this Creatinine Clearance

_____hrs ______min

c. Total amount of time the

corrected for body surface area,

Yes

using standard methods? (See

Unknown

patient is dry during

_____hrs ______min

instructions on page 6)

24 hours

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

23H. 24 hr DIALYSATE volume

4. Nighttime Prescription

(prescribed and ultrafiltration)

___ ___ ___ ___ ___mL

(excluding last bag fill)

___ ___ ___ ___

a. Volume of a single

mL/exchange

23I. 24 hr DIALYSATE urea nitrogen:

___ ___ ___

___ mg/dL

nighttime exchange

b. Number of dialysis

23J. 24 hr DIALYSATE creatinine:

___ ___

___ mg/dL

_____________

exchanges during the

(#/nighttime)

nighttime

23K. 24 hr URINE volume:

(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

___ ___ ___ ___

daytime exchange

mL/exchange

23L. 24 hr URINE urea nitrogen:

___ ___ ___

___ mg/dL

b. Number of dialysis

exchanges during the

23M. 24 hr URINE creatinine:

___ ___ ___

___ mg/dL

_____________

daytime

(#/daytime)

23N. SERUM BUN at the time this

PD adequacy assessment was done

___ ___ ___ mg/dL

6. Does the prescription described

above include TIDAL dialysis?

Yes

Unknown

23O. SERUM creatinine at the time this

PD adequacy assessment was done

___ ___

___ mg/dL

24C. Based on the adequacy

result from questions 23A-O,

23P.1.If the patient has had a 4-Hour

____

_____ _____

1. Was the collection repeated?

Yes

Unknown

D/P Cr performed from a PET since the

time of the first adequacy test, enter the

____ / ____ / _____

2. Was the prescription changed?

Yes

Unknown

value and the date the test was performed.

(mm)

(dd)

(yyyy)

If not performed, enter NP.

CMS – 821 (Rev.1/20/05)

Form Cms-821 - Peritoneal Dialysis Clinical Performance Measures Data Collection - 2005 Page 4

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