Post-Liver Transplant Follow-Up Note

Date: [Date of encounter]

Visit Type: [routine follow-up / urgent]; [clinic / telehealth]

Reason for Visit: [Primary reason for visit]

Transplant Summary

Transplant Date / Time Post-Transplant: [Date] / [time since transplant]
Indication: [Primary disease leading to transplant]
Donor/Recipient CMV Status: [D+/R- / D+/R+ / D-/R+ / D-/R-] (Include only if relevant to surveillance)
Rejection History: [Date, type, and treatment / none]
Significant Complications: [Relevant complications / none]
Current IS Strategy: [CNI-based / steroid-free / mTOR-based / other]

Interval History

[Interval summary since last visit] (1–3 paragraphs covering: graft dysfunction symptoms, infection symptoms, medication adherence with timing of last IS dose, new medications from outside providers, IS side effects, hospitalizations/ED visits, and relevant lifestyle factors. Clearly distinguish patient-reported from chart-derived information.)

Current Medications

Immunosuppression:

• [IS agent name]: [dose and schedule]. Level: [value] on [date] ([trough confirmed / timing unknown / pending / not drawn]). Target: [range]. Changes: [dose change with date and reason / none].
• [Additional IS agents as above]

Prophylaxis:

• [Agent, indication, and intended duration or stop date] (Include CMV strategy: prophylaxis vs preemptive monitoring. If not on standard prophylaxis, document reason.)

Other Medications: [Relevant non-IS medications by class]

Allergies: [Allergen and reaction type / NKDA / unknown]

Objective

Vitals: [BP, HR, Temp, Weight, SpO2 as relevant]

Exam: [Pertinent findings including general appearance, skin for jaundice/rash, cardiorespiratory, abdomen with attention to tenderness/organomegaly/ascites/incision, extremities for edema, neuro for tremor/asterixis as relevant]

Data Reviewed:

• Labs: [Key labs as trends with dates—include LFTs, synthetic function, renal, CBC, electrolytes, drug levels] (State if pending or unavailable rather than omitting.)
• Infection Surveillance: [CMV PCR, EBV, hepatitis markers as applicable]
• Imaging/Biopsy: [Study, date, key findings] (Include only if obtained.)

Assessment & Plan

(Organize by problem, ordered by clinical severity and graft risk.)

Graft Function

[Status summary with supporting data] (If abnormal, specify pattern and differentials. Use "no current clinical/laboratory features suggesting rejection" rather than declaring absence of rejection without biopsy.)

• Actions: [Diagnostics, treatments, biopsy threshold]
• Monitoring: [Lab timing, escalation criteria]

Immunosuppression

[Regimen confirmation and level interpretation with timing caveats]

• Current regimen: [IS agents and doses]
• Level interpretation: [Value, timing context, target]
• Changes today: [New dose/schedule with reason / none]
• Adherence: [Patient-reported adherence] (Do not infer from levels.)
• Monitoring: [Next level timing, toxicity surveillance plan]

Infection Prevention

• Prophylaxis: [Current agents, durations, monitoring cadence]
• Vaccinations: [Indicated vaccines with timing constraints]
• Education: [Key precautions and call-back instructions]

[Additional Problems]

[Status and supporting data]

• Actions: [Problem-specific interventions]
• Monitoring: [Follow-up plan and escalation thresholds]

(Add problems as relevant: renal/CKD, metabolic, bone health, malignancy surveillance, disease recurrence, surgical complications, psychosocial/adherence.)

Coordination: [Communications with team members, pharmacy, outside providers; pending records]

Orders: [Labs with due date, imaging, medication changes]

Follow-Up: [Return interval; contingency instructions for fever, jaundice, inability to take meds; who to call]