Living Donor Post-Op/Follow-Up Clinic Note

Date/Time: [Encounter date and time]

Provider: [Provider name, credentials]

Encounter Type: [in-person / telehealth]

Organ Donated: [kidney (left/right) / liver (segment/lobe)]

Procedure/Approach: [Surgical procedure and approach]

Date of Donation: [Donation date]

Time Since Donation: [POD# / weeks / months / years]

Visit Type: [early post-op / mandated longitudinal follow-up / problem-focused interim visit]

Subjective

[Reason for visit and time since donation] (One concise opening sentence.)

[Interval recovery course] (Summarize overall trajectory, pain status with current management, wound/incision concerns, functional recovery milestones including mobility and return to work/driving, and GI or urinary symptoms as applicable to donor type.)

[Complications or unplanned care since last contact] (If none, state explicitly that there have been no ED visits, readmissions, or new complications.)

[Current medications] (List current medications and supplements. Note any nephrotoxic or hepatotoxic exposures relevant to donor type.)

[Psychosocial status] (Include for longitudinal visits: brief check on mood, coping, and donation-related concerns. Document response if significant distress or safety concerns identified.)

[Work status and activity level] (Note current status, ongoing restrictions, and need for employer documentation.)

Objective

Vitals: [BP, HR, weight/BMI as relevant] (Note if donor-reported for telehealth.)

Exam: [Pertinent findings: general appearance, abdominal exam, incision status, extremities as indicated] (For telehealth, note visualization method or that exam was limited.)

Labs: [Relevant values with collection date] (Kidney donors: creatinine/eGFR, urinalysis, UACR. Liver donors: hepatic panel. State if pending, obtained externally, or not obtained with reason.)

Assessment & Plan

[Summary statement] (One to two sentences stating time since donation, overall recovery status, and key issues for this visit.)

[Problem-oriented assessment and plan] (Document each active problem in order of clinical importance with brief assessment and management plan. Typical problems include: post-donation recovery status with restrictions, pain management and taper plan, wound or hernia concerns, organ function monitoring with lab interpretation and plan for abnormalities, new medical issues post-donation, and psychosocial concerns if present.)

Follow-Up: [Next visit timing, pre-visit labs with instructions, how results will be communicated, and PCP coordination as applicable]

Follow-Up Counseling

(Include at mandated longitudinal time points only.)

[Counseling provided] (Document that the following were reviewed with donor: required follow-up schedule and lab monitoring expectations, lifelong preventive care and primary care relationship, lifestyle guidance appropriate to donor type, medication safety, and reproductive counseling if applicable. Note donor understanding. If any items deferred, document reason and plan to complete.)