Living Donor Surgical Evaluation Note

Date/Time: [Date and time of encounter]

Location: [Clinic or hospital site / telehealth]

Encounter Type: [Initial surgical evaluation / follow-up surgical evaluation] for living donation

Evaluating Surgeon: [Name, credentials]

Referral Source: [Self / recipient team / external clinician]

Interpreter: [Not used / language and interpreter ID] (Include only if interpreter services were used or offered.)

Donation Context & Donor Autonomy

(This section is ethically and regulatorily required and must be included every visit.)

• Organ under consideration: [Kidney / liver]
• Donation type: [Directed / non-directed / paired exchange]
• Donor–recipient relationship category: [Spouse/partner / family / friend / altruistic] (Do not include recipient health information.)
• Autonomy and voluntariness: [Documentation that donor understands they may withdraw at any time; recipient will not be informed of withdrawal without donor permission; confidentiality expectations reviewed] (If not discussed today, explicitly state it is planned for the next visit.)
• Independent Living Donor Advocate (ILDA): [Assigned / pending / not yet assigned]; [Name if assigned]

Chief Concern

[Brief statement of surgical evaluation for potential living kidney or liver donation and today's specific objectives, such as anatomy review, approach selection, or risk counseling]

Donor Surgical History

[Narrative summary of donor's goals and preferred surgery timeline]

[Functional status and activity tolerance; summary of what elements of donor workup are completed versus pending]

• Prior abdominal operations: [List with location and surgical relevance] (Upper abdomen particularly relevant for liver; lower abdomen for kidney.)
• Bleeding or clotting history: [Bleeding disorders, easy bruising, VTE history, anticoagulation use]
• Pulmonary/cardiac symptoms relevant to anesthesia: [Dyspnea, OSA, chest pain, exercise tolerance]
• Kidney-specific history: [Nephrolithiasis, hematuria, UTIs, urologic procedures, congenital anomalies] (Include if kidney donation is under consideration.)
• Liver-specific history: [Hepatobiliary symptoms, fatty liver risk factors, hepatitis evaluation status, alcohol use patterns] (Include if liver donation is under consideration.)
• Pregnancy status: [Not applicable / currently pregnant / postpartum timeframe] (Include if applicable.)

Medical History, Medications & Allergies

Past Medical History: [Problem list including conditions relevant to surgical and anesthetic risk such as hypertension, diabetes/prediabetes, OSA, pulmonary disease, cardiac history, psychiatric history]

Past Surgical History: [List with year and approach when known; highlight abdominal and pelvic operations]

Medications: [Prescribed medications, OTC, herbals/supplements, NSAID use patterns, anticoagulants/antiplatelets with doses and frequencies if available]

Allergies: [Medication and non-medication allergies with reaction type; explicitly note contrast allergy history]

Social History & Recovery Feasibility

• Tobacco/nicotine: [Current / former / never]; [Type and quantity]; [Quit date if applicable]; [Cessation counseling provided if current user]
• Alcohol and substance use: [Patterns, frequency, last use; counseling or treatment history if applicable]
• Occupation and physical demands: [Job role; lifting requirements or safety-sensitive duties]
• Care partner for postoperative period: [Identified person and availability; home support plan]
• Travel/lodging logistics: [Distance from center, transportation plan, lodging arrangements]

[Brief summary statement on recovery feasibility and identified supports or barriers]

Physical Exam

Vitals: [BP, HR, RR, Temp, SpO2, Height, Weight, BMI]

• General: [Appearance, distress level]
• Cardiopulmonary: [Heart sounds and rhythm; respiratory effort and breath sounds]
• Abdomen: [Scars, hernias, tenderness, organomegaly]
• Extremities: [Edema, pulses if relevant]

(For telehealth encounters, explicitly document exam limitations and any self-reported metrics or observations.)

Data Review

(Clearly distinguish reviewed data from pending studies. Use date-stamped entries. Include only data explicitly reviewed this visit.)

Labs:

• [CBC (date): key values]
• [CMP (date): key values]
• [Creatinine/eGFR (date): values] (For kidney donors.)
• [AST/ALT/ALP/Tbili, INR, platelets (date): values] (For liver donors.)
• [Pregnancy test (date): result] (If applicable.)
• [Other pertinent labs (date): results]

Cardiopulmonary Evaluation:

• [EKG (date): pertinent findings]
• [CXR (date): pertinent findings]
• [Additional testing such as stress test or echocardiogram (date): results] (If performed.)

Imaging:

• [Modality and region (date): images personally reviewed / relied on radiology report; key findings with surgical relevance]
• [Additional imaging (date): images personally reviewed / relied on report; key findings]

(If critical imaging is pending, explicitly state that surgical approach or laterality cannot be finalized.)

Pending studies: [List tests or consultations pending with expected dates, or "None"]

Anatomic Suitability & Operative Feasibility

(Include the organ-specific subsection relevant to the donation being considered. Use "pending" rather than inference when critical determinants are not yet available.)

Kidney Donation

(Include if kidney donation is under consideration.)

• Kidney size and parenchyma: [Symmetry; masses, cysts, or stones; parenchymal quality]
• Vascular anatomy: [Left kidney arteries (number, early branching); left renal vein (length, variants); right kidney arteries; right renal vein; notable variants such as retroaortic/circumaortic, gonadal/adrenal/lumbar veins]
• Collecting system and ureter: [Anomalies, duplication, ureteral course]
• Split renal function: [Left % / Right % / pending / not indicated]
• Proposed donation side: [Left / right / not yet determined] with rationale [e.g., preserve better-functioning kidney, vascular complexity considerations]
• Surgical complexity flags: [Multiple arteries / short renal vein / prior ipsilateral surgery / high BMI / anticipated adhesions / none identified]

Feasibility summary: [Concise statement of anatomic suitability and anticipated complexity]

Liver Donation

(Include if liver donation is under consideration.)

• Graft under consideration: [Left lateral segment / left lobe / right lobe]
• Volumetrics: [Projected graft volume] and [donor remnant volume], or pending; [graft-to-recipient weight ratio if used]
• Vascular anatomy: [Hepatic artery variants; portal vein branching; hepatic veins and outflow considerations]
• Biliary anatomy: [MRCP status and findings; expected ductal anatomy; anticipated need for reconstruction]
• Parenchyma: [Steatosis assessment via imaging or biopsy; fibrosis markers if available]
• Surgical complexity flags: [Small remnant / complex biliary anatomy / steatosis / variant vasculature requiring reconstruction / none identified]

Feasibility summary: [Concise statement of anatomic suitability and anticipated complexity]

Proposed Operation & Approach

• Procedure: [Laparoscopic donor nephrectomy / robotic donor nephrectomy / open donor nephrectomy / living donor right hepatectomy / living donor left hepatectomy / living donor left lateral segmentectomy]; [Tentative pending workup / finalized]
• Approach rationale: [Rationale based on anatomy, BMI, prior surgery, and center expertise]
• Contingency planning: [Conversion to open possible; triggers that may require conversion or reconstruction]
• Anticipated reconstructions: [Vascular / biliary / none anticipated]
• Blood products: [Expected transfusion likelihood]; [Consent status]

Risk Counseling & Informed Consent

• Participants: [Donor alone / donor with support person(s)]; [Interpreter used: yes/no, language if yes]
• General perioperative risks discussed: Anesthesia complications; bleeding with possible transfusion; infection; injury to adjacent organs; hernia; DVT/PE; chronic pain; conversion to open; readmission; reoperation; ICU care; death.
• Evaluation-related risks: [Contrast reactions; incidental findings and downstream testing]
• Kidney donor–specific counseling: Bowel and vascular injury; ileus; wound complications; expected reduction in kidney function post-nephrectomy; long-term risks of hypertension, proteinuria, CKD, and ESKD. (Include if kidney donation.)
• Liver donor–specific counseling: Bile leak and stricture; hepatic insufficiency or failure; bleeding; infection; vascular thrombosis; pulmonary complications; long-term hernia and abdominal wall symptoms. (Include if liver donation.)
• Psychosocial/financial/insurance considerations: [Addressed by program; donor questions documented with responses]
• Consent status: [Full informed consent completed / partial counseling completed]; [Topics covered today]; [Topics remaining and plan to complete]

(Avoid absolute statements such as "safe" or "no risk." Focus on donor voluntariness and support needs.)

Expected Postoperative Course

• Expected length of stay: [Number of days]
• Pain management: [Approach and multimodal plan]
• Activity restrictions: [Lifting limits; driving restrictions; return to exercise timeline]
• Return to work: [Timeline based on occupation and physical demands]
• Follow-up schedule: [Surgical clinic visits]; [Required OPTN living donor follow-up intervals at 6 months, 1 year, 2 years]
• Red flag symptoms and contact pathway: [Key symptoms warranting contact and how/when to reach the team or present for care]

Assessment

[One-paragraph summary of donor candidate, organ type, key anatomy highlights, significant risk modifiers, and what remains pending]

Candidacy status: [Provisional candidate pending imaging/labs / acceptable surgical anatomy pending committee review / not a surgical candidate due to (specific reason) / deferred requiring optimization/workup]; [Case will be presented to multidisciplinary living donor selection committee: yes/no and timing]

Plan

1. Living donor surgical candidacy: [Current status and plan for committee presentation]
2. Anatomic planning: [Laterality or liver segment selection status; approach decision status; items pending before finalization]
3. Perioperative optimization: [Smoking cessation timeline / weight management targets / cardiac risk evaluation / other specific needs, or "None required"]
4. Scheduling: [Estimated timeline; prerequisites to complete before scheduling]
5. Donor education: [Materials provided; key questions addressed; additional resources or referrals]

Return precautions and follow-up: [When to call or return; next appointment plan]

Attestations

(Include only attestations that apply to this encounter.)

• Imaging review attestation: [I personally reviewed the images and interpret the findings as documented / I relied on the radiology report with key findings as above]
• Time statement: [Total minutes spent on this encounter, including pre-visit review, face-to-face or telehealth time, and post-visit documentation and care coordination] (If billing by time.)
• Telehealth attestation: [Encounter conducted via audio/video; patient location; clinician location; consent obtained; exam limitations acknowledged] (If telehealth encounter.)

(Documentation reminders: Use "pending" for items not yet reviewed. Do not document recipient pressures; maintain donor focus and voluntariness. Do not declare the donor cleared or approved if key workup items remain outstanding.)