Labs Report And Forms > Ecfmonthlylabsnutritioncommunicationform

Facility Name Phone Number Extended Care Facility Monthly Labs & Nutrition Communication Date:________________ ECF: _________________________________ Patient’s Name: _______________________________ Prescribed dry weight:____________kg ( ____________lb) Postdialysis weight :_____________kg ( ____________lb) Weight (fluid) gains: between dialysis treatments__________kg ( ____________lb) : above prescribed dry weight_________ kg (____________ lb) PROBLEM(S) IDENTIFIED: NONE  Dry weight issues: Gained / Lost ___kg ( ___lb) [ ____% change] over a period of _____weeks / months  Excessive fluid gains:  Abnormal lab results:

 Other: ********************************************** RECOMMENDATION(S): NONE  Tube feeding: No change Increase / Decrease rate to:_____cc/hr Change formula to:________________________________________________ Other:___________________________________________________________  Intake: Increase / Decrease Protein Kcalories Other:____________________________________________________________  Limit intake: Na / K / Phosphorus / Fluids ( _________cc per day) Other:____________________________________________________________  Meds: Give Phosphorus binders with meals / snacks (NOT DURING MED PASS) • Renagel 800 __________ • Phoslo _______________ • Fosrenol 500__________ • Tums or Oscal_________ Other meds:____________________________________________________________

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Miscellaneous:____________________________________________________________ ________________________________________________________________________ THANKS! Renal Dietitian Phone No:

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