Record Keeping, Quality Assurance and Regulatory Standards
The Record Keeping, Quality Assurance and Regulatory Standards domain tests accurate documentation, incident reporting, quality indicators and compliance with dialysis regulations and standards.
Core rules
- Document pre/post weights, vital signs, prescription, UF, medications, access assessment and patient response; sign and time entries.
- Report adverse events and near misses through the facility system; do not alter records retrospectively without policy.
- Track Kt/V, URR, hemoglobin, access infection, hospitalization and water quality; use data for improvement.
- Follow CMS/ESRD conditions, OSHA bloodborne pathogen rules and AAMI standards. Retain records per legal retention policy.
Worked example
Monthly Kt/V is 1.1, below the 1.2 target. Audit Qb, treatment time, dialyzer reuse, access recirculation and missed time; then implement a corrective plan and recheck. The number is a trigger for review, not a reason to blame the patient.
Traps
Do not chart by memory after the shift; do not document a complication without the intervention and response; do not treat quality data as punitive; do not release records without authorization.