Points c NHSN total IV antimicrobial start rates for patients on hemodialysis decreased from 2016 to 2020, but rates unsupported by NHSN surveillance documentation did not. c There were 80% of reporting hemodialysis facilities that had $1 unsupported IV antimicrobial start, and the fraction of facilities with unsupported starts increased yearly. c Accurate reporting and timely review of antimicrobial data is critical to understanding prescribing trends and practices in hemodialysis facilities.