Liver Transplant Evaluation Note

Patient Name: [Full name]

MRN: [Medical record number]

DOB: [MM/DD/YYYY]

Age: [Age in years]

Sex: [Sex assigned at birth / gender identity if different]

Encounter Date: [MM/DD/YYYY]

Location: [inpatient / outpatient] [Facility/unit if applicable]

Service: [Hepatology / Transplant Hepatology / Transplant Surgery / Other]

Referring Clinician: [Name, specialty, organization]

Reason for Referral: [Concise referral reason]

Evaluation Type: [initial / re-evaluation / expedited]

Current Transplant Status: [not listed / listed at this center / listed elsewhere / previously listed] [Center name, dates if known]

Intended Transplant Type: [deceased donor / living donor interest / combined organ]

Author: [Name, credentials]

Sources of Information: [patient / caregiver / outside records / EHR / interpreter used] (Distinguish patient-reported vs record-confirmed for high-stakes elements)

Committee Snapshot

• One-liner: [Single sentence summary, e.g., "Adult with [etiology] cirrhosis (decompensated by [complications]) undergoing LT evaluation."]
• Key Metrics:
  • ABO: [A / B / AB / O / pending] [Source, date] (Per OPTN Policy 3.3, requires confirmation from two separate blood samples)
  • MELD: [Score] [MELD 3.0 / MELD-Na / other version] (Include bilirubin, INR, creatinine, sodium, albumin with values and collection dates/times; note dialysis within prior 7 days and timing relative to labs)
  • Anthropometrics: Height [value], Weight [value], BMI [value] (Note trajectory if clinically relevant)
  • Frailty/Functional Status: [Tool used and result / not yet assessed]
  • HCC/CCA Status: [present / absent / suspected] [LI-RADS category if available] [Tumor burden summary] [Last imaging date] [Downstaging/locoregional therapy history if applicable]
• Readiness and Barriers:
  • Medical optimization needed: [yes / no] – [brief detail]
  • Surgical/anatomic complexity: [yes / no] – [PVT extent, prior surgery, vascular anomalies]
  • Psychosocial concerns: [yes / no] – [adherence risk, active substance use, support adequacy]
  • Financial/logistical barriers: [yes / no] – [insurance, housing, transportation]
• Testing Status: (3–10 bullets; focus on items influencing candidacy)
  • [Item]: [completed (date/result) / pending / abnormal – action required]
  • [Item]: [completed (date/result) / pending / abnormal – action required]
  • [Item]: [completed (date/result) / pending / abnormal – action required]
• Committee Recommendation: [approve for listing / approve pending items / defer / decline]
  • (If pending/defer: list specific required items with responsible service and target timeline)
  • (If decline: specify permanent vs potentially reversible and re-referral criteria)

History

Chief Concern: [One sentence referral question] (If inpatient, indicate trigger for expedited evaluation)

Liver Disease History: [Etiology with supporting evidence; timeline including diagnosis date, decompensation events with dates, key hospitalizations; complications status for each (present/absent/unknown): ascites (refractory status, paracentesis frequency, SBP history), variceal bleeding (date, last EGD findings), hepatic encephalopathy (severity, precipitants, current medications), hepatorenal syndrome/CKD/AKI episodes/dialysis, hepatopulmonary syndrome or portopulmonary hypertension suspicion, sarcopenia/malnutrition/frailty, prior TIPS (date, indication, outcome); current symptoms, trajectory, functional limitations, falls] (Mark "unknown/not assessed" where applicable and state plan to obtain)

Cancer History: [HCC/CCA details if applicable (cross-reference Snapshot); other malignancies with type, stage, treatment, remission dates; current age/sex-appropriate cancer screening status]

Comorbidities: [Cardiovascular (CAD, HF, arrhythmia, valvular disease); Pulmonary (COPD, asthma, OSA, pulmonary hypertension); Renal (CKD stage, proteinuria); Metabolic (diabetes control, obesity); Infection history (recurrent infections, chronic viral, TB risk factors); Hematologic (thrombosis history, anticoagulation)]

Surgical History: [Prior abdominal surgeries, bariatric surgery, portal vein thrombosis history, hernias, prior transplants]

Medications: [Cirrhosis-specific medications, anticoagulants/antiplatelets, opioids/benzodiazepines, immunomodulators, other relevant medications] (Note adherence concerns if present)

Allergies: [Allergies and reactions]

Social and Substance Use History: [Alcohol: last use date, typical quantity/pattern, withdrawal history, prior treatment programs, current addiction care engagement; Tobacco/nicotine: current status, pack-years, cessation plan; Other substances: cannabis, stimulants, opioids (prescribed and non-prescribed), IV drug use history; Employment/disability status; housing stability; transportation access; caregiver availability with relationships] (Label each element as "reported by patient" vs "confirmed in records." Do not infer abstinence or adequate support from silence—state "unknown" if not assessed.)

Psychiatric History: [Depression, anxiety, PTSD, psychosis, suicidality history, cognitive impairment; current treatment and stability] (If not yet assessed, state explicitly and indicate plan)

Physical Examination

(Document only clinically meaningful findings; avoid copying generic normal examination templates)

• Vitals: [BP, HR, RR, Temp, SpO2] [Oxygen requirement if applicable] [Orthostasis if assessed]
• General: [Appearance, sarcopenia, jaundice, asterixis, volume status assessment]
• Abdomen: [Ascites, tenderness, hernias, surgical scars]
• Neurologic: [Encephalopathy grade impression if applicable]
• Functional: [Gait and sit-to-stand observations if assessed]

Objective Data

• Laboratory Summary: [Most recent MELD components (bilirubin, INR, creatinine, sodium, albumin) with values and dates/times; CBC; renal function] (Note dialysis timing relative to creatinine draw; if labs not available, state "not available for review" and whether records requested)
• Imaging: [Modality, date, and main findings: portal/hepatic vein patency, PVT extent if present, lesion summary with measurements and LI-RADS if applicable, ascites, splenomegaly, collaterals; chest imaging findings if performed]
• Endoscopy and Procedures: [EGD date/findings including varices, banding history, portal hypertensive gastropathy; colonoscopy date/findings; TIPS details if applicable; paracentesis frequency and SBP culture results]
• Cardiac Evaluation: [ECG summary; TTE summary; stress testing or catheterization if performed] – Cardiology clearance: [obtained (date, by whom) / pending / not indicated (rationale)]
• Pulmonary Evaluation: [PFTs; ABG/oximetry; sleep study; pulmonary hypertension evaluation if applicable] – Pulmonology clearance: [obtained (date, by whom) / pending / not indicated]
• Nutrition and Frailty: [Weight trends, evidence of muscle loss, dietary intake concerns; frailty tool and result or "pending"; nutrition consult findings if available]
• Infectious Disease Screening: [HIV, HBV surface antigen/core antibody/surface antibody, HCV antibody and NAT; center-standard serologies; TB screening status] – Immunizations: HBV vaccination [complete / incomplete / contraindicated (reason)]; HAV immunity [yes / no]; pneumococcal, influenza, COVID-19, zoster [status]
• Health Maintenance Screening: [Colon cancer screening status; breast/cervical/prostate screening as appropriate; lung cancer screening if criteria met] (Specify pending items and relevance to candidacy timeline)

Multidisciplinary Evaluations

• Hepatology: [Indication for liver transplant; optimization plan for decompensation and comorbidities; HCC pathway alignment if applicable]
• Transplant Surgery: [Operative candidacy and anticipated complexity; additional imaging or consults needed; donor options (deceased vs living); technical contraindications if present; combined organ considerations if applicable]
• Social Work: [Support system reliability and primary caregiver plan; housing and transportation feasibility; financial/insurance status] – Financial clearance: [yes / no / pending]; [Health literacy and adherence ability assessment]
• Psychiatry/Psychology: [Mental health stability, cognitive concerns, treatment plan; standardized tool if used (name, score, interpretation, modifiable targets)] (Include when indicated by history; if not yet completed, state status and scheduled date)
• Addiction Medicine: [AUD/SUD severity, relapse risk factors, treatment engagement, toxicology monitoring plan per center policy, abstinence expectations and monitoring plan] (Include when substance use history present; do not document unsupported guarantees of future abstinence)
• [Other specialty consultations as applicable]: [Status and key findings]

Contraindication Screening

(Document status as Present, Absent, Unknown, or Requires Optimization for each item; cite evidence source. Do not infer absence from silence; pair "Unknown" with plan and timeline.)

• Absolute Contraindications:
  • Uncontrolled sepsis or active infection: [Present / Absent / Unknown / Requires Optimization] – Evidence: [source]
  • Active extrahepatic malignancy or unacceptable recurrence risk: [Present / Absent / Unknown / Requires Optimization] – Evidence: [source]
  • Severe non-correctable cardiopulmonary disease: [Present / Absent / Unknown / Requires Optimization] – Evidence: [source]
  • Ongoing substance use failing center criteria: [Present / Absent / Unknown / Requires Optimization] – Evidence: [source]
  • Inability to adhere to medical regimen (objective history): [Present / Absent / Unknown / Requires Optimization] – Evidence: [source]
  • Lack of minimum required support: [Present / Absent / Unknown / Requires Optimization] – Evidence: [source]
  • Uncontrolled psychiatric illness posing major adherence/safety risk: [Present / Absent / Unknown / Requires Optimization] – Evidence: [source]
• Relative/Modifiable Barriers:
  • Frailty/sarcopenia/malnutrition: [Present / Absent / Unknown / Requires Optimization] – Plan: [prehabilitation/nutrition intervention]
  • Obesity extremes or severe deconditioning: [Present / Absent / Unknown / Requires Optimization]
  • Active tobacco use: [Present / Absent / Unknown / Requires Optimization] – Cessation plan: [details]
  • High-risk anatomy: [Present / Absent / Unknown / Requires Optimization]
  • Renal dysfunction requiring liver-kidney pathway consideration: [Present / Absent / Unknown / Requires Optimization]
  • Addressable social barriers: [Present / Absent / Unknown / Requires Optimization]

Testing Checklist

(Indicate status: Completed [date/result], Ordered/Scheduled [date], or Outstanding [barrier/next step])

• Policy-Mandated Items:
  • ABO confirmation (two separate samples per OPTN 3.3): [fully confirmed (dates/sources) / pending]
  • MELD component labs: [bilirubin, INR, creatinine, sodium, albumin] – [dates, within acceptable window: yes/no]
  • HIV/HBV/HCV testing including NAT: [Completed (dates) / Ordered / Outstanding]
  • HBV vaccination status: [complete / incomplete / contraindicated] – Documentation: [yes / no]
  • Patient education provided (multiple listing, waiting time transfer per OPTN 3.2): [yes (date) / no]
• Standard Evaluation Items:
  • Cardiac testing (ECG, TTE, stress/cath as indicated): [Completed / Ordered / Outstanding]
  • Pulmonary testing (PFTs, ABG, sleep study as indicated): [Completed / Ordered / Outstanding]
  • Abdominal imaging with contrast: [Completed / Ordered / Outstanding]
  • Endoscopy (EGD) and colon cancer screening: [Completed / Ordered / Outstanding]
  • Psychosocial assessments: [Completed / Ordered / Outstanding]
  • Nutrition and frailty assessment: [Completed / Ordered / Outstanding]
  • Immunizations: [Up to date / Incomplete – plan]

Assessment

(Organize by problem in decreasing severity/urgency. Anchor each to objective data with dates. Explicitly address: primary liver indication and severity; HCC/CCA status if applicable; cardiopulmonary risk and clearance; renal dysfunction and combined organ considerations; infection risk and immunization gaps; frailty and nutrition; substance use and relapse risk plan when applicable; psychosocial readiness, adherence, and support. When stating "cleared," specify by whom and when.)

• Problem 1: [Diagnosis/clinical impression]
  • Assessment: [Concise synthesis with key data and dates; transplant relevance]
  • Plan: [Targeted actions with contingencies]
• Problem 2: [Diagnosis/clinical impression]
  • Assessment: [Summary]
  • Plan: [Actions]
• (Add additional problems as needed)

Plan

• Listing Recommendation: [approve / approve pending items / defer / decline] (Tie to center selection criteria and contraindication screening; if pending, list required items with responsible party and target timeline)
• Optimization and Bridge Management: [Cirrhosis complication management while awaiting decision; HCC bridging/downstaging plan if applicable; prehabilitation and nutrition targets; addiction treatment engagement and monitoring plan; vaccination timing relative to anticipated transplant]
• Coordination: [Communication to patient/caregiver; communication to referring clinician; follow-up appointments; ownership of outstanding items]

Patient Education and Consent

• Education provided: [Multiple listing options / transferring waiting time / transferring care without losing waiting time / program restrictions if any] – Materials provided: [yes / no] [Date]
• Counseling topics covered: [Evaluation process / surgical procedure and alternatives / medical and psychosocial risks / donor risk factors including infection transmission / right to refuse transplant]
• Infectious disease/transmission risk consent: [obtained (date) / deferred – reason and planned timing]
• (If education or consent deferred, document reason and when it will occur)

Signature

[Electronic signature], [Credentials], [Date/Time]