Kidney Transplant Follow-Up Note (Nephrology)

Date: [Date]

Encounter Type: [post-transplant follow-up / acute visit] — [in-person / telehealth]

Provider/Service: [Provider name and role / Service or clinic]

Reason for Visit: [Concise visit focus]

Transplant Center: [Transplant center name and coordinator contact, or "Unknown—records requested"]

Transplant Snapshot

(Update only when changes occur. Omit unknown details—do not guess.)

• Transplant Date: [Date] — [Time since transplant]
• Donor Type: [living / deceased]; CMV D/R: [status if known]; EBV D/R: [status if known]
• Induction: [Agent(s) if known]
• Maintenance Immunosuppression: [Current agents and strategy]
• Baseline Creatinine: [Value, date, usual range] (If unknown: "Baseline unknown—records requested")
• Rejection History: [Type and date if any, or "None"]
• Prior OIs of Note: [BK / CMV / recurrent UTIs / other, or "None"]
• Current Prophylaxis: [Agent(s) and planned stop dates, or "None"]
• IS Management: [Local nephrology / Transplant center / Shared]

Subjective

Chief Complaint: [One-line visit focus; list up to 3 key issues if multiple]

Interval History: [Narrative covering: hospitalizations/procedures/infections since last visit; graft-related symptoms (urine output, graft pain, edema, weight, fever, fatigue); infection symptoms; medication adherence with missed doses in last 7–14 days and barriers; timing of last CNI dose relative to lab draw; home monitoring (BP range, weight, glucose if diabetic). Document patient quotes for adherence barriers when helpful. If records incomplete, note what was requested.]

Transplant ROS: [Targeted review: constitutional, GU, GI (diarrhea/vomiting affecting absorption), respiratory, skin (new/nonhealing lesions), neuro (tremor/headache)] (If negative in stable patient: "Transplant ROS otherwise negative.")

Objective

Vitals: [BP with home comparison if available; HR; Temp; Weight; BMI]

Exam: [General appearance; volume status (edema, JVP); lungs; heart; abdomen/graft area (tenderness, bruit); skin; tremor assessment] (For telehealth: note observed elements and limitations.)

Labs/Data (include dates, trend indicators, and source for outside labs):

• Renal: [Creatinine with baseline comparison and trend direction; eGFR; BUN]
• Electrolytes: [K, Mg, Phos, HCO3 with pertinent abnormalities]
• UA/Proteinuria: [UA findings; ACR/UPCR or 24h protein]
• CBC: [WBC/ANC, Hgb, Plt; note cytopenias]
• IS Levels: [Drug, level, date/time, true trough: yes/no]
• Viral Surveillance: [BK PCR and CMV PCR: last result, date, next due]
• Other: [DSA, dd-cfDNA, biopsy findings, HbA1c as relevant]
• Pending/Unavailable: [Key labs not obtained—plan to obtain]

Assessment & Plan

(Problem-oriented format in priority order. Tie assessments to objective data. For each problem: brief assessment, plan with monitoring and contingency triggers, specify local vs transplant center management. Only label graft function as "stable" when supported by trend data. If data missing, document uncertainty and plan to obtain.)

[Problem-based assessment and plan addressing applicable issues: graft function with creatinine trend and differentials; immunosuppression management with level interpretation, dose changes, and authorization source; adherence with barriers and interventions; infection surveillance/prophylaxis status with next due dates; hypertension/volume; diabetes/PTDM if present; other comorbidities (electrolytes, bone-mineral, dyslipidemia, cytopenias); malignancy surveillance and skin exam status; vaccinations/health maintenance]

Transplant Center Coordination: [Who contacted, when, discussion points, agreed plan] (If not contacted when expected, document rationale.)

Follow-up: [Next appointment interval; labs ordered with timing and trough instructions; referrals placed; surveillance due dates (BK, CMV, proteinuria per protocol); return/ED criteria for earlier evaluation]