Dialysis Treatment Log Form
Use this form to record a dialysis treatment session, including patient details, pre- and post-treatment measurements, treatment parameters, and session notes.
Patient and Session Details
Patient Identifier
*
Patient Name
First Name
Middle Name
Last Name
Date of Treatment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Treatment Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Treatment End Time
*
Hour Minutes
AM
PM
AM/PM Option
Dialysis Location / Unit
*
Please Select
Inpatient Unit
Outpatient Dialysis Center
ICU
Emergency Department
Other
Treating Staff Name
*
First Name
Middle Name
Last Name
Treating Staff Role
*
Please Select
Registered Nurse
Dialysis Technician
Nephrologist
Nurse Practitioner
Physician Assistant
Other
Pre-Treatment Assessment
Pre-Treatment Weight (kg)
*
Pre-Treatment Blood Pressure (mmHg)
*
Pre-Treatment Pulse / Heart Rate (bpm)
*
Pre-Treatment Temperature (°C)
Vascular Access Type
*
Please Select
AV Fistula
AV Graft
Catheter
Other
Pre-Treatment Symptoms / Notes
Dialysis Treatment Parameters
Dialysis modality/type
*
Please Select
Hemodialysis
Peritoneal dialysis
Hemodiafiltration
Other
Prescribed treatment duration (minutes)
*
Actual duration completed (minutes)
*
Dialyzer/filters used
Blood flow rate (mL/min)
*
Dialysate flow rate (mL/min)
Ultrafiltration goal (mL)
Fluid removed (mL)
Post-Treatment Outcomes
Post-Treatment Weight
*
Post-Treatment Blood Pressure
*
Post-Treatment Pulse / Heart Rate
*
Post-Treatment Temperature
Treatment Completed as Prescribed
*
Yes
No
Post-Treatment Symptoms, Adverse Events, or Deviations Notes
Medications, Instructions, and Sign-Off
Medications Given During Dialysis
Heparin
Saline
Erythropoiesis-stimulating agent
Iron infusion
Vitamin D analog
Antibiotic
Other
Patient Instructions / Follow-Up Notes
Staff Confirmation
*
Please Select
Reviewed
Entered
Verified
Completed
Acknowledgment of Log Entry
I acknowledge that this dialysis treatment log entry is accurate to the best of my knowledge.
Not acknowledged
Save Treatment Log
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