Narrative Review: Acute Kidney Injury

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Site Patient AE Complication Event date AE code
xxx xxx x xx/xx/xxxx xxx

Demographic / Medical history

  • [age] year old [gender]
  • Past Medical History: [eg. CAD, Severe mitral stenosis, former tobacco use, dyslipidemia, ...]
  • Past Surgical History: [including date]

Procedure

  • Index Procedure Date/Time: xx/xx/xxxx at xx:xx [insert date and time]
  • Index Procedure Detail:
    • On [insert date and time] the subject underwent a [select surgical correction] for [select etiology].
    • Enter access site details
    • Baseline MR severity was classified as [select none, trace, mild, mild-moderate, moderate, moderate-severe-severe] and post-implant MR was classified as [select severity].
    • The site reported that there were/were not procedural complication(s).

Event(s)

Event (1):

  • Site Reported Event Onset Date: xx/xx/xxxx
  • Event summary:
    • Symptoms and sign: Subject presented with [sign and symptom] on xx/xx/xxxx.
    • Important characteristics of the chief complaint such as severity, site, and duration.
    • Other important symptoms related to the chief compliant.
    • Physical assessment:
    • Vital signs
    • Positive physical examinations or related negative examinations.

Event (2):

  • Site Reported Event Onset Date: xx/xx/xxxx
  • Event summary:
    • Symptoms and sign: Subject presented with [sign and symptom] on xx/xx/xxxx.
    • Important characteristics of the chief complaint such as severity, site, and duration.
    • Other important symptoms related to the chief compliant.
    • Physical assessment:
    • Vital signs
    • Positive physical examinations or related negative examinations.

Laboratory data and Imaging

  • Lab studies:
    • Bun/Cr levels
Date Time BUN/Cr Na/K Urine output
xx/xx/xxx xx:xx
xx/xx/xxx xx:xx
xx/xx/xxx xx:xx
    • Other labratory:
      • Date/ name/ value
  • ECG / date:
  • ECHO / date:
  • CXR / date:
  • Other imaging and diagnostic tests / date:

Consults

  • Date and time of consult
  • Suggested treatments

Clinical course

  • Date and time of events,
  • Dialysis / time
  • Patient condition got worse or better.

Treatment and outcome

  • List of relevant medical treatments
  • Out come [Discharge / Hospice / Death]
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