What is the correct way to document Chronic Kidney Disease (CKD) on progress notes for patients on dialysis?

Correct Documentation of CKD in Progress Notes for Dialysis Patients

For patients on dialysis, document as "CKD G5D" followed by the specific dialysis modality (hemodialysis or peritoneal dialysis), frequency, cause of kidney disease, and albuminuria category when known. 1

Essential Documentation Components

Primary Classification

• Use "CKD G5D" to indicate chronic kidney disease stage 5 treated by dialysis 1
• The "D" designation is critical to distinguish dialysis patients from those with CKD G5 not receiving kidney replacement therapy 1
• Never use outdated terms: ESRD, ESKD, end-stage renal disease, end-stage kidney disease, renal failure, chronic renal failure, or dialysis-dependent CKD 1

Dialysis Modality Specification

• Specify the exact modality: hemodialysis (HD), hemofiltration (HF), hemodiafiltration (HDF), or peritoneal dialysis (PD - ambulatory or automated) 1
• Document frequency: continuous versus intermittent (short or prolonged) 1
• For hemodialysis patients, include treatment schedule (e.g., "CKD G5D on hemodialysis three times weekly") 1
• Avoid terms like "chronic dialysis" or "acute dialysis" as these incorrectly refer to dialysis duration rather than kidney disease duration 1

Cause Classification

• Always document the underlying cause using the CGA classification system (Cause, GFR category, Albuminuria category) 1
• Specify the etiology: diabetic kidney disease, hypertensive nephrosclerosis, glomerulonephritis, polycystic kidney disease, etc. 1
• Do not infer cause solely from comorbid conditions; document only confirmed diagnoses 1

Albuminuria Category (When Applicable)

• Include albuminuria category (A1, A2, or A3) if measured prior to dialysis initiation or if residual kidney function exists 1
• A1: ACR <30 mg/g; A2: ACR 30-300 mg/g; A3: ACR >300 mg/g 1
• This component may be less relevant for anuric patients but should be documented when residual function exists 1

Complete Documentation Examples

Optimal format: "CKD G5D due to diabetic kidney disease, on hemodialysis three times weekly (Monday/Wednesday/Friday)"

Alternative format: "CKD G5D, A3 due to hypertensive nephrosclerosis, on peritoneal dialysis (continuous ambulatory)"

For transplant recipients: Use "CKD G1T-G5T" with the appropriate GFR category and specify "after transplantation" 1

Terms to Completely Avoid

• Never use: End-stage renal disease (ESRD), end-stage kidney disease (ESKD), renal failure, chronic renal failure, renal replacement therapy (RRT), dialysis-dependent, ESKF, ESRF 1
• Never use: Renal disease, nephropathy (except for specific diseases like membranous nephropathy), renal impairment, renal insufficiency, renal dysfunction, azotemia 1
• Never use: Non-dialysis CKD (ND-CKD), non-dialysis-dependent CKD (NDD-CKD), predialysis CKD, pre-ESRD CKD 1

Additional Clinical Documentation

Dialysis Adequacy Metrics

• For hemodialysis patients, document Kt/V values monthly to ensure adequate dialysis delivery 1
• Target delivered dose should be documented as spKt/V with the number of treatments per week 1
• Include urea reduction ratio (URR) when formal kinetic modeling is not available 1

Treatment Duration Specification

• Use "long-term dialysis" or "maintenance dialysis" for CKD patients rather than "chronic dialysis" 1
• Document treatment start date to establish disease chronicity (>3 months defines CKD versus acute kidney disease) 1

Monitoring and Referral Documentation

• Document nephrology involvement, as all CKD G5D patients require specialist care 1, 2
• Note frequency of monitoring (typically monthly for dialysis adequacy and laboratory parameters) 1

Common Pitfalls to Avoid

• Do not use "stage 5" alone without specifying treatment status (G5D for dialysis, G5 without KRT for non-dialysis) 1
• Do not omit the dialysis modality, as hemodialysis and peritoneal dialysis have different management implications 1
• Do not use "renal" terminology; the prefix "nephro-" or term "kidney" is preferred except for specific anatomic structures 1
• Do not document as "kidney failure" alone without specifying "with replacement therapy" (KFRT) or treatment modality 1
• Do not use vague descriptors like "advanced CKD" or "severe CKD" instead of the specific G5D classification 1