University of Wisconsin Hospital and Clinics
TITLE: Medical Records for Dialysis
Services provided to Middleton’s
Memorial Veterans Administration
REVISED: October 1, 2016
Page 1 of 8
Nurse Manager: Joan Watson, MS, RN
Director: Ann Malec, DNP, RN, NEA-BC
Medical Director: Alex Yevzlin, MD
The purpose of this policy is to state the practice of the UWHC Hemodialysis Department (HD)
regarding the maintenance of Medical Records for VAH patients who receive dialysis services
furnished by UWHC HD staff under contract. Refer to UWHC Administrative Policy 6.39 Legal
Medical Record for detailed information regarding the elements that comprise the Legal Medical
Record (LMR), UWHC Administrative Policy 6.21 Security of Paper Record for detailed
information regarding the physical security of paper records and UWHC Administrative Policy
4.39 Electronic Medical Record Audit Policy regarding the security provided for electronic
A. University Wisconsin Hospital and Clinics (UWHC) maintains a medical record (which
may include paper and electronic information) for all patients, both inpatient and
outpatient, who receive Hemodialysis or Continuous Renal Replacement Therapy
(CRRT) and other related services under contract.
1. Hemodialysis treatment records typically include-
a) Consents for Hemodialysis
b) Hemodialysis and other treatment related procedure orders
c) Medication Administration Record
d) Hemodialysis flow sheet rows (electronic) or
Hemodialysis Nurses Notes (paper)
e) Hemodialysis Treatment Summary Handoff Note.
2. CRRT treatment records typically include –
a) Initial, Maintenance, Termination and Re-initiation Progress Notes
B. This documentation exists in paper-based or electronic-based forms dependent upon the
location of services delivered. The VAH requires a copy of all documentation for services
provided under contract and disclosure of information to VAH for VAH patients who
receiving hemodialysis treatment at UWHC is covered under contract.
C. In addition to the above, the VAH requires a progress notes to be entered into the VAH
electronic medical record summarizing care provided.
1. Hemodialysis Treatment Summary note is written for VAH patients receiving
hemodialysis treatment services at UWHC or VAH.
2. CRRT Initial, Maintenance, Termination or Re-initiation Progress Notes are
written for VAH patients receiving these CRRT support services at the VAH.
Page 2 of 8
A. Documentation that comprises the LMR may physically exist in either paper-based or
electronic-based forms as described below.
B. Paper Documents
1. UWH form # 301644-DT and UWH form # 301551-DT Consent to Operations,
Anesthetics, Diagnostic Radiology, Transfusion, or other Procedures – Renal
Replacement Therapy and Central Venous Catheter Insertion.
a) Used to obtain consent for hemodialysis treatment, hemodialysis catheter
placement when a VAH patient is consented at UW Hospital & Clinics
2. UWH form # 4008566-DT, Hemodialysis Nurses Notes
a) Used to record hemodialysis treatment set-up, safety checks, anticoagulation,
treatment related medications, blood products, assessments and monitoring of
VAH patients receiving hemodialysis treatment at VAH.
3. UWH form #SR300014, Physician Orders – Hemodialysis
a) Used to write hemodialysis treatment orders on VAH patients receiving
hemodialysis treatment at UWHC and VAH.
C. Electronic Documentation
1. The UWHC Hemodialysis encounter report summarizes treatment information
entered into UWHC’s electronic medical record for VAH patient receiving
Hemodialysis treatment at UWHC and includes the following:
a) All Medications and Administrations
b) Order Report
c) Lab Results
d) Handoff Notes
e) Provider Progress Notes
D. Document filing:
a) Obtained at UWHC are scanning into the electronic medical record and a copy
is faxed to the VA Hospital medical records (fax # 608-830-6655).
b) Obtained at Middleton Veteran Administration Hospital contact VAH
inpatient unit to ask that a copy of the consent be faxed to UWHC
Hemodialysis department (fax # 608-262-4893) and subsequently scanned
into the electronic medical record.
2. Hemodialysis Treatment records
a) UWH form # 4008566-DT, Hemodialysis Nurses Notes and UWH form
#SR300014, Physician Orders – Hemodialysis will be faxed to the VA
Hospital medical records (fax # 608-830-6655), the original copy will be
placed in the VAH inpatient chart and subsequently scanned into the
electronic medical record.
b) UWHC Hospital encounter report will be faxed to the VA Hospital medical
records (fax # 608-830-6655) and the original copy will be placed in the VAH
3. CRRT progress notes will be entered into the VAH electronic medical record
summarizing care provided and a copy of that note will be printed and
subsequently scanned into UWHC electronic medical record.
Page 3 of 8
A. UWHC Administrative Policy 4.17 Informed Consent
B. UWHC Administrative Policy 6.39 Legal Medical Record
C. UWHC Administrative Policy 6.21 Security of Paper Record
D. UWHC Administrative Policy 4.39 Electronic Medical Record Audit Policy
REVIEWED: Jan 2017
Page 4 of 8
UWH form #SR300014, Physician Orders – Hemodialysis
Page 5 of 8
UWH form # 4008566-DT, Hemodialysis Nurses Notes
Page 6 of 8
Page 7 of 8
UWH form # 1289139, Consent
Page 8 of 8