Labs Report And Forms > Nursinghomefaxform-0002

Alamo City Dialysis Center 805 Camden San Antonio, TX 78215 210-527-1308 Fax: 210-527-0691

FRESENIUS MEDICAL CARE, NA

FAX To:______________________________

From:___________________________

Fax Number:______________________

Date:___________________________

PATIENT NAME:_____________________________________________________________ SS#___________________________________ Estimated Dry Weight_____________ Fluid Weight Gain between treatments: Stated appetite: Potassium: Phosphorus:

DOB_________________________________

Stable_____ Loss_____ Gain_____ Acceptable_____ Excessive_____ Good_____ Fair_____ Poor_____ WNL_____ Decreased_____ Increased_____ WNL_____ Decreased_____ Increased_____

Prescribed Phosphorus Binder_____________________________________________________ Recommended Diet Order________________________________________________________ Recommendations: _____ Protein (Albumin) level is below normal. Encourage patient to increase protein intake. _____ Add protein powder to appropriate foods for an additional _______grams of protein/day. _____ Increase protein/calorie intake with appropriate liquid supplement__________________. _____ Patient unable to eat without assistance. Please coordinate with staff to provide assistance. _____ Patient is missing a meal during dialysis. Please send sack meal. _____ Patient does not consistently bring sack meal. Please coordinate with appropriate staff. _____ Potassium levels consistently high. Decrease potassium foods and monitor closely. _____ Glucose levels consistently elevated. Contact patient’s primary care provider. _____ Glucose levels consistently low. Contact patient’s primary care provider. _____ Phosphorus levels elevated. Please coordinate with nursing to ensure binders arrive with meals. _____ Please coordinate with nursing to ensure daily multivitamin is given. _____ Fluid intake is excessive. Fluid weight gain should be 3kg or less between each treatment. Comments: ___ See attached patient monthly nutrition labs ___ Monthly nutrition labs sent home with patient ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ This fax and/or any documents accompanying it may contain confidential information belonging to the sender. This information is intended only for the use of the individual or entity named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying or distribution of this information is strictly prohibited. If you received this fax in error, please call 210-527-1308 to notify us.