Form CMS-2744A END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM ESRD

Form Approved
OMB No. 0938-0447

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FOR THE PERIOD

END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM
ESRD FACILITY SURVEY (DIALYSIS UNITS ONLY)

Facility Physical Address
(If different than mailing address)

Suite/Room Street

City

State/Zip Code

Number of Dialysis Stations:

Facility Telephone: (

Facility Ownership Type: ■ Profit

■ Non-Profit

)

Facility Local/National Affiliation/Chain Information
(i.e. Gambro, etc.)

Types of dialysis services offered:

■ Incenter Hemodialysis

■ Peritoneal Dialysis

■

Home Hemodialysis Training

Does your facility offer a dialysis shift that starts at 5:00 p.m. or later?

■ Yes

■

No

DIALYSIS PATIENTS AND TREATMENTS
DIALYSIS PATIENTS
Additions During Survey Period
Started Restarted
for first
time ever

Patients Receiving Care
Beginning of Survey Period
Incenter

Home

Total
Fields 01
thru 02

Losses During Survey Period

Transferred
from
other
dialysis
unit

Returned
after
transplantation

Deaths

Recovered
kidney
function

06A
06B

07A
07B

08A
08B

09A
09B

TransDisReceived
ferred to continued
transother dial- dialysis
plant
ysis unit

Other
(LTFU)

Incenter
Home

01

02

03

04A
04B

05A
05B

10A
10B

11A
11B

12A
12B

13A
13B

Patients Receiving Care at End of Survey Period
Incenter
Dialysis

Total
Incenter
Dialysis

Self-Dialysis Training

Home Dialysis

Total
Home
Dialysis

Total
Patients

HemoDialysis

Other

HemoDialysis

CAPD

CCPD

Other

Fields 14
thru 19

HemoDialysis

CAPD

CCPD

Other

Fields 21
thru 24

Fields 20
and 25

14

15

16

17

18

19

20

21

22

23

24

25

26

Patient Eligibility Status
End of Survey Period
Currently Medicare
enrolled
applicain
tion
Medicare pending

Hemodialysis Patients Dialyzing
More Than 4 Times Per Week
Setting

NonMedicare

Day

Nocturnal

30A
30B

31A
31B

Incenter
Home

27

28

29

Vocational Rehabilitation
Patients
Patients
Patients
attending
Patients receiving
Employed
school
aged 18
services
full-time or
full-time or
through 54 from Voc
part-time
part-time
Rehab

32

33

34

35

TREATMENT AND STAFFING
Staffing
Number of Staff

Incenter Dialysis Treatments
(Include Training Treatments)

COMPLETED BY (Name)

Hemodialysis

Other

36

37

Position
a. RNs
b. LPN/LVNs
c. PCTs
d. APNs
e. Dietitians
f. Social Workers

DATE

Number of Open Pos.

Full Time

Part Time

Full Time

Part Time

38

39

40

41

TITLE

TELEPHONE NO.

REMARKS REGARDING INFORMATION PROVIDED ON THIS SURVEY SHOULD BE ENTERED ON THE LAST PAGE OF THE SURVEY
This report is required by law (42 USC 426; 42 CFR 405.2133). Individually identifiable patient information will not be disclosed except as provided for in the Privacy Act of 1974
(5 USC 5520; 45 CFR, Part 5a).
Form CMS-2744A (02/04)
Expires XX/XX/XXXX