1) history of present renal illness
2) past medical history and surgical history
3) history of renal disease such as dialysis, peritoneal dialysis, or declining renal function
4) current medications; giving explanation of what each medication is meant to do and how it should be taken
5) lab reports; series of lab data is helpful to explain the case. Provide an explanation on the significance of the lab data.
6) Discussion; discuss the progress of the presenting illness, medical interventions, nursing interventions and expected outcomes
7) what have i learned or what did i find interesting during this treatment of care