Nephrology APCM Care Plan Documentation Checklist

Clearly state the current eGFR and classify the patient into CKD Stage 3a, 3b, 4, or 5 based on KDIGO guidelines.

Record the most recent Urine Albumin-to-Creatinine Ratio to assess risk of progression and cardiovascular complications.

Define specific BP goals (e.g., <120/80 mmHg) and document current antihypertensive therapy, including ACEi or ARB usage.

Document if the CKD is secondary to Diabetes Mellitus, Hypertension, PKD, or Glomerulonephritis to tailor the care plan.

Review the last 12-24 months of data to determine if the patient is a 'rapid progressor' requiring more frequent AI-driven check-ins.

Audit the patient's full medication list to ensure all drugs are adjusted for current eGFR to prevent toxicity.

Document recent lab values and any prescribed potassium binders or phosphate binders for mineral bone disease.

Record Hemoglobin levels and document the use of Iron therapy or Erythropoiesis-Stimulating Agents (ESAs).

Verify and document that the patient has been counseled on the risks of OTC NSAIDs and other nephrotoxic agents.

Track Parathyroid Hormone and Vitamin D levels to manage secondary hyperparathyroidism effectively.

Record discussions regarding Hemodialysis, Peritoneal Dialysis, and Home HD to ensure the patient is informed of choices.

For Stage 4/5 patients, document the status of fistula/graft referral or PD catheter placement planning.

Note if the patient has been referred for transplant evaluation or if they are currently on the UNOS waiting list.

Define dry weight targets and document the patient's protocol for reporting sudden weight gains via AI call handling.

Ensure the care plan includes a referral to a renal dietitian for low-sodium, low-potassium, or low-protein dietary guidance.