IDT Rounding Worksheet

Negash, Menberish DOB: 12/30/1951 | MPI: 2204789

Filters
Include Section: Active Allergies; Active Dialysis Access(es); Problem List; Labs; Treatment Info; Visit Info; Peritoneal Equilibration Test(s) (PET); Active Treatment Order(s);
Active Medication(s); Active Protocol Order(s); Hospitalization Event(s) (Within the last 31 days); Microbiology Culture, Antibiotic
Primary Nephrologist: Upadhyay, Ashish MD Actual DaVita Start Date: 01/23/2020 Advance Care Plan Status: Full Code
Renal Function Status: ESRD Regular Chronic Dialysis Began: 03/28/2020 Latest PHQ-9 Score: 0,01/24/2023
Diabetic Status: Diabetes Mellitus - Type 2 Treatment Schedule: M W F; Shift 2 (03035) Height (BMI): 63.00in / 5ft 3.00in / 160.02cm (28.1)
Modality Status: In-Center Hemodialysis (ICHD) Treatment Duration: 03:33 (213 mins) Target Weight (TW): 72.0 kg (158.7 lbs)

* Last Used Access(es)

ACTIVE ALLERGIES ACTIVE DIALYSIS ACCESS(ES) SITE DATE PLACED

No Known Allergies *AV Fistula Upper Arm (Left) 06/24/2020

PROBLEM LIST

No Data Available.

🏥 Outside labs may use a different unit of measure | Underlined: Out of Range

LABS

ANEMIA JAN 2024 DEC 2023 NOV 2023 ADEQUACY JAN 2024 DEC 2023 NOV 2023

HEMOGLOBIN (g/dL) 11.5 (12/27) STDKT/V (DIAL) N/A (01/03) N/A (12/06) N/A (11/01)

Drawn (01/08) 12.3 (12/20) 12 (11/21) SPKT/V 1.92 (01/03) 2.14 (12/06) 2.57 (11/01)

11.8 (01/03) 11.8 (12/06) 11.9 (11/01) STDKT/V TOTAL N/A (01/03) N/A (12/06) N/A (11/01)
IRON SATURATION 25 (01/03) 30 (12/06) BUN (mg/dL) 52 (01/03) 43 (12/06) 62 (11/01)
(%)
BUN - POST (mg/dL) 10 (01/03) 7 (12/06) 8 (11/01)
FERRITIN (ng/mL) 929 (01/03) 1061 (12/06)
URR% (%) 81 (01/03) 84 (12/06) 87 (11/01)
IRON (ug/dL) 65 (01/03) 77 (12/06)
CREATININE (mg/dL) 8.1 (01/03) 7.3 (12/06) 7.73 (11/01)
MCV (fL) 93.2 (01/03) 93.7 (12/06) 94 (11/01)
NUTRITION JAN 2024 DEC 2023 NOV 2023
TIBC (ug/dL) 261 (01/03) 260 (12/06)
ALBUMIN (g/dL) 4.1 (01/03) 4.3 (12/06) 4.2 (11/01)
WBC (x 10'3 cells/uL) 8.9 (01/03) 8.6 (12/06) 8.4 (11/01)
NPCR (G/KG/D) 0.88 (01/03) 1.01 (12/06) 1.54 (11/01)
MBD JAN 2024 DEC 2023 NOV 2023
POTASSIUM (mEq/L) 5.1 (11/21)
CA CORRECTED 9.4 (01/03) 9.7 (12/06) 9.4 (11/01)
(mg/dL) 5.7 (12/20) 5.1 (11/08)

CALCIUM (mg/dL) 9.4 (01/03) 9.7 (12/06) 9.4 (11/01) 5.8 (01/03) 4.9 (12/06) 5.4 (11/01)

PHOSPHORUS 3.8 (01/03) 4.1 (12/06) 4.9 (11/01) SODIUM (mEq/L) 137 (01/03) 140 (12/06) 137 (11/01)
(mg/dL)
CO2 (mEq/L) 24 (01/03) 27 (12/06) 27 (11/01)
PTH-INTACT (pg/mL) 230 (01/03) 154 (12/06) 327 (11/01)

TREATMENT INFO (03035) BOSTON DIALYSIS

TREATMENT DATE 01/08/24 01/05/24 01/03/24 12/31/23 12/29/23 12/27/23 12/24/23 12/22/23 12/20/23 12/18/23 12/15/23 12/13/23 12/11/23

TREATMENT ORDER ICHD ICHD ICHD ICHD ICHD ICHD ICHD ICHD ICHD ICHD ICHD ICHD ICHD
TYPE

FACILITY (03035) (03035) (03035) (03035) (03035) (03035) (03035) (03035) (03035) (03035) (03035) (03035) (03035)

Pre Weight (kg) 74 74 75.1 74 75.5 73.5 74.1 75 74.4 75.3 74.1 74 75.4

Post Weight (kg) 72 72 72.7 72.8 72 71.6 72.5 73.4 72.7 73 72 72.5 73.4

Target Weight (kg) 72 72 72 72 72 72 72 72 72 72 72 72 72

IDWG (kg) 2.0 1.3 2.3 2.0 3.9 1.0 0.7 2.3 1.4 3.3 1.6 0.6 3.3

DISCLAIMER: Printing information from CWOW should be limited due to regulatory compliance requirements. When printing is desired, it should only be for valid operational, clinical or treatment purposes and
consistent with DaVita policies and procedures. One must promptly shred or properly dispose the printed information when the purpose for which it was printed is completed. Failure to adhere to these requirements
may result in disciplinary action, up to and including termination of employment with DaVita.

BOSTON DIALYSIS (03035)

Page 1 of 4 | ver. R19.0.0.0-CWOW-104424 660 HARRISON AVE, BOSTON, MA 02118-2304 Printed
IDT_v.1.0.3_R19 © 2024 DaVita Inc. 01/08/2024 15:13 EST
IDT Rounding Worksheet
Negash, Menberish DOB: 12/30/1951 | MPI: 2204789

TREATMENT INFO (03035) BOSTON DIALYSIS

TREATMENT DATE 01/08/24 01/05/24 01/03/24 12/31/23 12/29/23 12/27/23 12/24/23 12/22/23 12/20/23 12/18/23 12/15/23 12/13/23 12/11/23

TREATMENT ORDER ICHD ICHD ICHD ICHD ICHD ICHD ICHD ICHD ICHD ICHD ICHD ICHD ICHD
TYPE

FACILITY (03035) (03035) (03035) (03035) (03035) (03035) (03035) (03035) (03035) (03035) (03035) (03035) (03035)

IDWG % of TW 2.8% 1.8% 3.2% 2.8% 5.4% 1.4% 1% 3.2% 1.9% 4.6% 2.2% 0.8% 4.6%

Machine Set To
2400 2600 2500 2000 3000 2100 2000 2500 2000 2500 2000 2200 2000
Remove (mL)

Total Volume
2408 1962 2260 1500 2862 2100 2000 2504 2006 2500 2005 2199 2005
Removed (mL)

Ultrafiltration Rate
7.8 7.6 9.3 4.7 14.6 7.9 6.6 6.1 6.4 9.0 8.3 5.9 7.7
(ml/kg/hr)

Pre BP Sit (mmHg) 109/51 113/55 135/66 103/54 122/62 123/56 109/64 131/63 114/57 107/53 126/61 101/72 124/64

Post BP Sit (mmHg) 121/53 118/77 131/96 106/55 126/62 124/64 135/72 142/70 132/85 118/57 126/67 136/78 122/73

Lowest BP (mmHg) 85/22 54/31 97/58 53/24 91/61 114/58 85/47 97/70 100/65 107/53 103/56 87/47 106/46

Prescribed Tx Time
3:30 3:30 3:30 3:30 3:30 3:30 3:30 3:30 3:30 3:30 3:30 3:30 3:30
(HH:MM)

Actual TX Time
03:33 03:40 03:32 03:29 03:20 03:22 03:20 03:33 03:39 03:30 03:31 03:30 03:32
(HH:MM)

NOTE: 5% of Current Target Weight is 3.6 kg

VISIT INFO

No Data Available.

PERITONEAL EQUILIBRATION TEST(S) (PET)

No Data Available.

ACTIVE TREATMENT ORDER(S)

IN-CENTER HEMODIALYSIS TREATMENT - [BOSTON DIALYSIS] (03035) Order ID: 241009082

Start Date 11/17/2023 Sequential UF N Sodium Modeling N

End Date - Max UF Rate 13 mL/kg/hr Base Sodium 138 mEq/L
Justification What is the justification?
End Stage Renal Disease Dialyzer Fresenius, Optiflux, UF Profiling Y (Every Treatment)
(ESRD) (N18.6,Z99.2); F160NR, 1025 Profile(s) #14
Frequency/TX Time Three times a week (210 Dialysate Bath FMC, ACID - LIQUID,
mins) 2K-2.5Ca, 55 GAL Provider Upadhyay, Ashish MD
Target Weight 72 kg DRUM Collaborating Physician -
Blood Flow Rate 450 mL/min Bicarbonate 38 mEq/L
Dialysate Flow Rate 800 mL/min Dialysate Temperature 36°C

Concurrent Access No
Arterial Access AV Fistula (Upper Arm
(Left))
Arterial Needle NIPRO, TULIP, 15G x 1",
SHARP , TWIN
Venous Access AV Fistula (Upper Arm
(Left))
Venous Needle NIPRO, TULIP, 15G x 1",
SHARP , TWIN

DISCLAIMER: Printing information from CWOW should be limited due to regulatory compliance requirements. When printing is desired, it should only be for valid operational, clinical or treatment purposes and
consistent with DaVita policies and procedures. One must promptly shred or properly dispose the printed information when the purpose for which it was printed is completed. Failure to adhere to these requirements
may result in disciplinary action, up to and including termination of employment with DaVita.

BOSTON DIALYSIS (03035)

Page 2 of 4 | ver. R19.0.0.0-CWOW-104424 660 HARRISON AVE, BOSTON, MA 02118-2304 Printed
IDT_v.1.0.3_R19 © 2024 DaVita Inc. 01/08/2024 15:13 EST
IDT Rounding Worksheet
Negash, Menberish DOB: 12/30/1951 | MPI: 2204789

ACTIVE TREATMENT ORDER(S)

SEQUENTIAL TREATMENT - [BOSTON DIALYSIS] (03035) Order ID: 1900816410

Start Date 11/05/2022 Sequential UF N Sodium Modeling N

End Date - Max UF Rate 13 mL/kg/hr Base Sodium 138 mEq/L
Justification What is the justification?
End Stage Renal Disease Dialyzer Gambro, Revaclear, Auto Flow No
(ESRD) (N18.6,Z99.2); 300, 1218 UF Profiling Y (Every Treatment)
UF Justification Fluid Bicarbonate 38 mEq/L Profile(s) #19
overload due to UF Dialysate Temperature 36.5°C
intolerance (E87.79); Provider Bhatia, Jasvinder S. MD
Fluid Overload UF Collaborating Physician -
Documentation
Intradialytic
hypotension;
Frequency/TX Time One time only (120
mins)
Target Weight 72 kg
Blood Flow Rate 450 mL/min
Dialysate Flow Rate 800 mL/min

Concurrent Access No
Arterial Access AV Fistula (Upper Arm
(Left))
Arterial Needle NIPRO, TULIP, 15G x 1",
SHARP , TWIN
Venous Access AV Fistula (Upper Arm
(Left))
Venous Needle NIPRO, TULIP, 15G x 1",
SHARP , TWIN

*Per Protocol Order

ACTIVE MEDICATION(S) Bundle Type: ALL

IN-CENTER MEDICATION DOSE/ROUTE/FREQUENCY FACILITY PROVIDER START DATE

*Mircera 75 Microgram, Intravenous, ESA dosing, every four BOSTON DIALYSIS(03035) Bhatia, Jasvinder, 01/04/2024
weeks S.MD
*Calcitriol 2.25 Microgram, Oral, Three times a week BOSTON DIALYSIS(03035) Bhatia, Jasvinder, 12/12/2023
S.MD
Heparin Pork, Hourly Dose 500 Units/Hr, Intravenous, Every Dialysis Treatment | BOSTON DIALYSIS(03035) Bhatia, Jasvinder, 09/18/2022
Stop Time 60 minutes S.MD
Heparin Pork, Loading Dose 1,000 Units, Intravenous, Every Dialysis Treatment BOSTON DIALYSIS(03035) Bhatia, Jasvinder, 09/18/2022
S.MD
HOME MEDICATION DOSE/ROUTE/FREQUENCY PROVIDER START DATE

Ammonium Lactate 1 Application, External, As needed 06/27/2022

Daily-Vite 1 Tablet, Oral, One time a day 06/27/2022
Lanolin Alcohol 1 -, Not Applicable, Two times a day 06/27/2022

Provider Instructions: apply BID to affected areas.

Lantus 8 Unit, Subcutaneous, Every evening 06/27/2022

Pantoprazole Sodium 20 Milligram, Oral, One time a day 06/27/2022
valACYclovir HCl 500 Milligram, Oral, One time a day 06/27/2022
Acetaminophen 500 Milligram, Oral, Every six hours 12/04/2021
Aspirin 81 Milligram, Oral, One time a day 12/04/2021
Carvedilol 12.50 Milligram, Oral, Two times a day 12/04/2021
Loratadine 10 Milligram, Oral, One time a day 12/04/2021
NIFEdipine 120 Milligram, Oral, One time a day 12/04/2021

DISCLAIMER: Printing information from CWOW should be limited due to regulatory compliance requirements. When printing is desired, it should only be for valid operational, clinical or treatment purposes and
consistent with DaVita policies and procedures. One must promptly shred or properly dispose the printed information when the purpose for which it was printed is completed. Failure to adhere to these requirements
may result in disciplinary action, up to and including termination of employment with DaVita.

BOSTON DIALYSIS (03035)

Page 3 of 4 | ver. R19.0.0.0-CWOW-104424 660 HARRISON AVE, BOSTON, MA 02118-2304 Printed
IDT_v.1.0.3_R19 © 2024 DaVita Inc. 01/08/2024 15:13 EST
IDT Rounding Worksheet
Negash, Menberish DOB: 12/30/1951 | MPI: 2204789
*Per Protocol Order

ACTIVE MEDICATION(S) Bundle Type: ALL

HOME MEDICATION DOSE/ROUTE/FREQUENCY PROVIDER START DATE

Nateglinide 60 Milligram, Oral, With meals 12/04/2021

Provider Instructions: TID

Sevelamer Carbonate 1,600 Milligram, Oral, With meals 12/04/2021

Provider Instructions: 2--800mg tabs TID

Tradjenta 1 Tablet, Oral, One time a day 12/04/2021

Provider Instructions: 5mg

Simvastatin 10 Milligram, Oral, One time a day 01/29/2020

ACTIVE PROTOCOL ORDERS START DATE LAST REVIEW DATE

ICHD Oral Calcitriol Given In-center (Rev 2.0) 04/26/2023 12/11/2023

ICHD SHAPE IV Mircera rev 4.2 04/11/2023 01/04/2024
ICHD Iron Works (IV Iron Sucrose) Protocol, Hold for Ferritin > 800, Revision 4.1 09/18/2022 01/04/2024
Oral Nutrition Supplement (ONS) Protocol (rev 3.0) 09/18/2022 12/11/2023
MBD Lab Monitoring Protocol (Revision 1.0) 09/18/2022
Hepatitis C Surveillance Twice a Year Protocol Rev 3.1 09/18/2022

HOSPITALIZATION EVENT(S) Within the last 31 Days

No Data Available.

🏥 Outside Labs may use a different unit of measure

MICROBIOLOGY CULTURE

No Data Available.

ANTIBIOTIC

No Data Available.

The purpose of this worksheet is for the interdisciplinary team to review clinical information and discuss observations while rounding with providers. If notes are handwritten on this
worksheet it must be retained in the medical record.

Name

Signature Date

DISCLAIMER: Printing information from CWOW should be limited due to regulatory compliance requirements. When printing is desired, it should only be for valid operational, clinical or treatment purposes and
consistent with DaVita policies and procedures. One must promptly shred or properly dispose the printed information when the purpose for which it was printed is completed. Failure to adhere to these requirements
may result in disciplinary action, up to and including termination of employment with DaVita.

BOSTON DIALYSIS (03035)

Page 4 of 4 | ver. R19.0.0.0-CWOW-104424 660 HARRISON AVE, BOSTON, MA 02118-2304 Printed
IDT_v.1.0.3_R19 © 2024 DaVita Inc. 01/08/2024 15:13 EST