Abstract: Objective: To develop and validate a tool for hierarchical nursing grading in hemodialysis patients, thereby providing a standardized instrument for clinical nursing practice. Methods: A preliminary tool was constructed through literature review, qualitative interviews, and a Delphi expert consultation. Later 335 patients admitted to a tertiary grade A hospital hemodialysis center from May to June 2025 were conveniently selected as samples for the validation study. In order to finalize the tool, we conducted item analysis, inter-rater reliability testing, and compared the grading results obtained using the tool with the results analyzed subjectively by nurses. Results: The final tool comprised primary assessment (15 items) and instant assessment (11 items). Substantial agreement was observed between the results obtained by the tool and clinical nurses subjectively with a weighted Kappa of 0.617. Cross-tabulation analysis showed that compared with the subjective grading, patients with a higher score according to the tool often tend to have objective clinical risk indicators. Inter-rater reliability testing showed a Kendall's W of 0.817 (P<0.001). Conclusion: The assessment tool demonstrates good reliability and validity, providing scientific basis for the precise stratification and graded nursing of hemodialysis patients.

Key words: hemodialysis; Triangle model; hierarchical classification; nursing grading; assessment tool; Delphi method