Post-Transplant Discharge Summary (Recipient)

Patient: [Patient name] | MRN: [MRN] | DOB/age: [DOB / age] | Sex: [sex]

Transplant: [organ type: kidney / liver / heart / lung / pancreas / multi-organ] | Transplant date: [MM/DD/YYYY]

Admission: [MM/DD/YYYY HH:MM] | Discharge: [MM/DD/YYYY HH:MM] | Length of stay: [LOS in days]

Primary service: [Primary service] | Transplant program: [Program name]

Attending: [Attending name, credentials] | Primary surgeon: [Surgeon name, credentials] | Discharging clinician: [Name, credentials]

Disposition: [home / home with services / rehab / SNF / LTACH] [Receiving facility name if applicable]

Transplant clinic contact: [Clinic phone] | Coordinator: [Coordinator name / coordinator line]

Isolation status: [Isolation status at discharge] (Include if applicable)

Communication needs: [Interpreter/communication needs] (Include if applicable; specify language, modality, and caregiver support)

Brief Discharge Summary

[Concise 4–8 sentence summary of hospitalization and transplant course] (Include: reason for admission and transplant procedure with date; immediate postoperative level of care [ICU vs floor], extubation status, and hemodynamic stability; graft function trajectory stated explicitly as a trend using arrow notation [e.g., Cr 8.2 → 1.6], not a single value; major complications with key interventions and dates; discharge readiness including diet tolerance, mobility level, pain control, and lab stability; maintenance immunosuppression regimen overview and therapeutic drug monitoring plan including trough frequency; first transplant clinic date. Use absolute dates for all events.)

Discharge Diagnoses

• [Principal discharge diagnosis] (The transplant episode if index admission; if readmission, list the primary complication first. Use fully specified terms with site/organism/anatomy when known; label as "suspected" if not confirmed and provide brief supporting evidence.)
• [Secondary diagnosis 1]
• [Secondary diagnosis 2]
• [Transplant-related complication(s)]
• [Comorbidities that affected care or management]

Transplant Details

Donor type: [living / deceased / DCD]

Induction therapy: [Agent(s), total dose, date range] (Use absolute dates.)

Intraoperative issues: [Significant blood loss, transfusions, vasopressors, complications] (Brief summary; detailed operative narrative in op note.)

Drains/stents: [Type and location] | Removal plan: [Timeline and responsible service]

Serostatus: CMV [D+/− / R+/−], EBV [D+/− / R+/−] (Add others per program as needed.)

Immunologic highlights: [Crossmatch result], [DSA status], [HLA mismatch summary if relevant]

Organ-Specific Details

(Include only the subsection matching this patient's transplant type.)

Kidney: Cold ischemia time: [minutes]; Warm ischemia time: [minutes]; Ureteral stent: [yes / no]; planned removal: [date/location]; Delayed graft function: [yes / no]; Dialysis during admission: [yes / no]; [dates and modality if yes]

Liver: Biliary reconstruction: [Type]; T-tube/external drain: [status and plan]; Initial Doppler: [arterial/portal flow findings]; Early allograft dysfunction: [concerns and evidence, or "none"]

Heart: Ischemic time: [minutes]; Pacing wires: [present / removed]; Initial echo: [EF, RV function, valvular findings]; Endomyocardial biopsy schedule: [dates/frequency]

Lung: Transplant type: [single / bilateral]; Airway issues: [anastomosis status/complications]; Baseline spirometry plan: [details]; Surveillance bronchoscopy schedule: [dates/frequency]

Pancreas: Drainage: [enteric / bladder]; Anticoagulation plan: [agent, dose, duration, monitoring]

Hospital Course

(Organize by problem using short paragraphs with embedded absolute dates. List transplant-critical problems first. For high-risk domains like rejection and infection, state "none suspected" explicitly rather than omitting.)

1. Allograft Function and Monitoring

[Brief issue statement] [Objective evidence and trend with dates] [Interventions performed with dates] [Current status at discharge] [Outpatient plan: what to monitor, who follows, when]

2. Rejection Evaluation/Treatment

[None suspected / suspected / confirmed] (If suspected or confirmed: include biopsy/imaging/lab evidence with dates; treatment given with dates and doses; response; and specific post-discharge monitoring and biopsy/imaging schedule.)

3. Infectious Complications and Prophylaxis Initiation

[Infections during admission with organism/site and key culture/imaging data, or "no infections identified"] [Therapy given with dates] [Prophylaxis started and rationale] [Status at discharge and outpatient monitoring/ID follow-up if applicable]

4. Immunosuppression Management and Adverse Effects

[Agents used, dose changes with dates, level trends, adverse effects observed] [Current regimen and monitoring plan] [Drug interactions addressed]

5. Surgical/Wound/Drain Issues

[Incision/wound status] [Drain/stent issues] [Interventions and dates] [Discharge care instructions and removal plan with responsible service]

6. Major Non-Transplant Complications

[Cardiac/pulmonary/GI/neurologic/hematologic/endocrine issues as applicable, or "none"] [Objective data and interventions with dates] [Status at discharge and responsible outpatient services with timelines]

Graft Function Trend

Trend Table

Date	Key Markers	Supporting Tests
[Pre-transplant baseline date]	[Baseline marker values]	[Relevant baseline tests]
[Peak/worst date]	[Peak/worst marker values]	[Supporting tests at peak/worst]
[Most recent date]	[Most recent marker values]	[Most recent supporting tests]

(Organ-specific markers: Kidney—Cr, BUN, K, 24h urine output. Liver—AST, ALT, T.bili, INR. Heart—EF, BNP, hemodynamics. Lung—O2 requirement, FEV1. Pancreas—glucose trend, amylase/lipase, C-peptide.)

Interpretation

[Brief interpretation: improving / stable / worsening] (If not improving as expected, state differential considered and workup performed.)

Immunosuppression

Induction

[Agent(s), total dose administered, date range, notable adverse events] (Use absolute dates.)

Maintenance Regimen at Discharge

• [Agent 1: generic name, dose, route, frequency, formulation, start date or "continued"; taper schedule if applicable; indication if for rejection treatment rather than maintenance]
• [Agent 2: details as above]
• [Agent 3: details as above]

Therapeutic Drug Monitoring Plan

• Target range: [e.g., trough 8–10 ng/mL for first month] (If not documented: "Target trough per transplant protocol—verify with transplant pharmacist/attending before signing.")
• Last level: [MM/DD/YYYY], [value with units]
• Monitoring frequency: [e.g., twice weekly with clinic labs]
• Dose adjustments during admission: [Brief timeline with dates and rationale]

Drug Interactions and Toxicity Monitoring

• Interactions addressed: [Critical interactions addressed at discharge: azoles, macrolides, grapefruit products, etc.]
• Toxicity monitoring: [Key labs: CBC, CMP, magnesium, phosphorus, lipids, glucose; vitals: blood pressure]

Prophylaxis Schedule

Indication	Agent	Dose/Route/Frequency	Start Date	Stop Date/Duration	Monitoring
CMV prevention	[Agent or "preemptive monitoring" or "not indicated"]	[Dose/Route/Frequency]	[MM/DD/YYYY]	[Stop date or duration]	[Viral load schedule and lab routing]
PJP prophylaxis	[Agent or "not indicated"]	[Dose/Route/Frequency]	[MM/DD/YYYY]	[Stop date or duration]	[CBC for leukopenia]
Fungal prophylaxis	[Agent or "not indicated"]	[Dose/Route/Frequency]	[MM/DD/YYYY]	[Stop date or duration]	[Drug level/LFTs if applicable]
HSV/VZV prophylaxis	[Agent or "not indicated"]	[Dose/Route/Frequency]	[MM/DD/YYYY]	[Stop date or duration]	[Renal dosing; CBC]
HBV/HCV prophylaxis or treatment	[Agent or "not indicated"]	[Dose/Route/Frequency]	[MM/DD/YYYY]	[Stop date or duration]	[Viral load and LFT schedule]
Bacterial prophylaxis	[Agent or "not indicated"]	[Dose/Route/Frequency]	[MM/DD/YYYY]	[Stop date or duration]	[Culture follow-up]
GI ulcer prophylaxis	[Agent]	[Dose/Route/Frequency]	[MM/DD/YYYY]	[Stop date or duration]	[Mg/B12 if long-term]
Bone protection	[Agent or "not indicated"]	[Dose/Route/Frequency]	[MM/DD/YYYY]	[Stop date or duration]	[Vitamin D, calcium, DEXA]
VTE prophylaxis	[Agent or "not indicated"]	[Dose/Route/Frequency]	[MM/DD/YYYY]	[Stop date or duration]	[Bleeding risk; platelets]

Discharge Medications

(Complete reconciled list grouped by category. Use generic names.)

• Immunosuppression:
  • [Medication, dose, route, frequency]
• Prophylaxis/anti-infectives:
  • [Medication, dose, route, frequency]
• Cardiometabolic:
  • [Medication, dose, route, frequency]
• GI/bowel regimen:
  • [Medication, dose, route, frequency]
• Analgesia:
  • [Medication, dose, route, frequency]
• Other:
  • [Medication, dose, route, frequency]

Medication Changes

[Home medications stopped and why; new medications started and why; dose changes and rationale; duplication risks addressed]

High-Risk Medication Notes

(Include each subsection only if applicable to this patient.)

• Anticoagulants: [Indication, planned duration, monitoring responsibility]
• Insulin/diabetes agents: [Regimen summary, glucose targets, hypoglycemia plan]
• Opioids: [Planned course duration, taper plan if applicable, bowel regimen]

Functional Status and Devices

Functional status: [Mobility and ADL baseline vs at discharge; PT/OT involvement; equipment ordered]

Lines/drains/devices at discharge: [Type, location, indication, care instructions, removal plan and responsible service]

Wound care: [Incision appearance; dressing type and change frequency; staple/suture removal date and location]

Home services: [Home health nursing, infusion services, home lab draws, dialysis if applicable, DME]

Pending Results

• [Test pending] — Expected: [date]; Responsible: [Service/clinician]; Action if abnormal: [Action]; Notification: [How receiving clinician will be notified]

(Add additional items as needed. Do not imply likely results; document uncertainty explicitly.)

Follow-Up Plan

Appointments

• Transplant clinic: [MM/DD/YYYY HH:MM or "to be scheduled by (coordinator name)"]
• Specialty follow-up: [Service, date, indication]
• PCP: [Recommended timeframe]
• Other: [Rehab, wound check, drain clinic as applicable]

Laboratory Schedule

• Labs required: [Specific tests: CBC, CMP, tacrolimus trough, magnesium, phosphorus, CMV PCR, others]
• Frequency: [e.g., twice weekly × 4 weeks, then weekly × 4 weeks]
• Location: [Where labs will be drawn]
• Results routing: [Where results are sent and who reviews]

Surveillance Testing

[Organ-specific surveillance schedule: biopsies, Doppler/ultrasound, echocardiogram, chest radiograph, PFTs, viral load monitoring. Include timing with absolute dates when scheduled and responsible service.]

Care Responsibilities

• Transplant clinic: Immunosuppression dosing, prophylaxis duration, graft surveillance
• Infectious Diseases: [Antimicrobial management] (Include if ID involved)
• Surgery: [Drain/stent removal, wound care]
• Primary Care: Chronic disease management in coordination with transplant once stable

Return Precautions

Call transplant team immediately for:

• Inability to take immunosuppression (vomiting, medication access issues)
• Fever ≥ 100.4°F or chills
• Wound redness, increased drainage, or opening
• Medication side effects requiring urgent review (severe tremor, confusion, severe diarrhea, bleeding)

Organ-specific symptoms: (Include only those relevant to this transplant type.)

• Kidney: Decreased urine output, graft site pain or swelling, dark or bloody urine
• Liver: Yellowing of skin/eyes, pale stools or dark urine, right upper quadrant pain
• Heart: New/worsening shortness of breath, leg swelling, weight gain > 2–3 lbs/day, palpitations, lightheadedness/syncope
• Lung: Increased shortness of breath, new/changed cough or sputum, oxygen saturation decline, chest pain
• Pancreas: Persistent nausea/vomiting, abdominal pain, blood glucose consistently elevated

Go to nearest ED and notify transplant center for:

• Severe symptoms (chest pain, severe shortness of breath, altered mental status, uncontrolled bleeding)
• Symptoms not improving after contacting transplant team

Contact information:
Transplant clinic: [phone] | 24-hour transplant line: [phone] | Nearest transplant-affiliated ED: [location]

Infection Prevention Counseling Documented

[Education provided regarding infection prevention strategies, exposure avoidance, food safety, and vaccine timing considerations. Note whether teach-back was performed and whether caregiver was present.]