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Audit Tools

• Hemodialysis Catheter Connection & Disconnection Observations [PDF – 200 KB]
• Hemodialysis Catheter Exit Site Care Observations [PDF – 260 KB]
• Arteriovenous Fistula & Graft Cannulation and Decannulation Observations [PDF – 400 KB]
• Hemodialysis Hand Hygiene Observations [PDF – 150 KB]
• Dialysis Station Routine Disinfection Observations [PDF – 280 KB]
• Injection Safety Medication Preparation & Administration Observations [PDF – 280 KB]

All Data Collection Forms are Print-only

Survey

• Outpatient Dialysis Center Practices Survey Form – January 2024 (57.500) [PDF – 250 KB]
  • Table of Instructions [PDF – 500 KB]

Monthly Reporting Plan

• Dialysis Component Monthly Reporting Plan form – January 2024 (57.501) [PDF – 100 KB]
  • Customizable form [DOCX – 80 KB]
  • Table of Instructions [PDF – 300 KB]

Summary Form

• Dialysis Prevention Process Measure Summary Form – January 2024 (57.504) [PDF – 100 KB]
  • Customizable form [DOCX – 80 KB]
  • Table of Instructions [PDF – 250 KB]