Pre-Transplant Admission H&P (Recipient)

Date/Time of Encounter: [date and time]

Call-In Time: [date and time]

Arrival Time: [date and time]

Transplant Type: [organ]

Donor Type: [living / deceased (DBD / DCD / unknown)]

Location: [ED / direct admit / ICU / other]

History Source: [patient / caregiver / chart / other] (Include interpreter ID if used; note reliability concerns if any.)

Chief Complaint

[Chief complaint] (Single sentence stating patient called in for potential [organ] transplant.)

History of Present Illness

[Underlying organ failure etiology, listing status, and current offer context] (Focus on changes since last transplant evaluation rather than duplicating prior workup. Use uncertainty language where appropriate as offer may change after organ inspection.)

Offer and Compatibility Details:

• Listing status and date: [active / inactive; reason if inactive]
• Offer source and donor type: [OPO identifier; living / deceased (DBD / DCD)]
• Anticipated organ(s): [single organ / multi-organ (specify)]
• ABO compatibility: [compatible / incompatible / unknown]
• Crossmatch status: [negative / positive / virtual only / pending] (Include collection/result times if available.)
• Donor transmissible disease flags: [none / HIV / HBV / HCV / PHS increased risk / other] (Note consent requirement and status.)

Interval Events Since Last Transplant Assessment: (Include dates for all relevant events.)

• Infections or recent febrile illness: [source, treatments, culture status, antibiotic dates]
• Cardiopulmonary events: [chest pain, syncope, arrhythmia, HF exacerbation, new oxygen requirement]
• Recent procedures/surgeries: [type, date, complications, bleeding issues]
• Anticoagulant/antiplatelet exposure: [agent, last dose date/time, indication]
• Immunologic sensitizing events: [transfusions, pregnancy; dates and details]
• Hospitalizations/ED visits: [dates, diagnoses, treatments]
• Caregiver or logistics changes: [availability, contact changes]

Kidney/Dialysis Module: (Include only if kidney recipient or dialysis-dependent; omit entirely otherwise.)

• Dialysis modality and schedule: [in-center HD / home HD / PD; usual days/times]
• Last dialysis: [date/time; ultrafiltration volume if available]
• Dialysis access: [AVF / AVG / tunneled catheter / PD catheter]; [function concerns, infections, recent interventions]
• Residual urine output: [volume/day or anuric]
• Dry weight and current weight: [volume status relative to dry weight]
• Heparin exposure: [last dose time/amount or heparin-free]

Liver/Cirrhosis Module: (Include only if liver recipient; omit entirely otherwise.)

• Ascites: [none / mild / moderate / tense]; [diuretic response]; [paracentesis frequency, last date and volume]; [SBP history/prophylaxis]
• Encephalopathy: [baseline vs current grade]; [precipitants]; [lactulose/rifaximin adherence]; [safety concerns]
• Varices: [last endoscopy date/findings; banding/TIPS history]
• Renal function: [baseline creatinine; HRS trajectory; dialysis dependence if present]

Focused Symptom Screen:

• Fever/chills: [present / absent / not assessed]
• Respiratory symptoms: [present / absent / not assessed]
• GI symptoms (nausea, vomiting, diarrhea): [present / absent / not assessed]
• Dysuria or urinary symptoms: [present / absent / not assessed]
• Skin/line infection symptoms: [present / absent / not assessed]
• Chest pain or syncope: [present / absent / not assessed]
• Neurologic deficits: [present / absent / not assessed]
• Recent COVID/flu exposure per local policy: [yes / no / unknown]; [test dates and results if available]

NPO and Time-Critical Medication Timing:

• NPO since: [date/time]; Last solids: [date/time]; Last liquids: [date/time]
• Anticoagulants/antiplatelets: [agent; last dose date/time]
• Insulin/SGLT2 inhibitor: [agent; last dose date/time]
• GLP-1 receptor agonist: [agent; last dose date/time]
• Opioids/benzodiazepines: [agent; last dose date/time]
• Lactulose/rifaximin: [agent; last dose date/time] (If applicable.)
• Diuretics: [agent; last dose date/time]
• Dialysis-unit heparin: [dose and last administration time] (If applicable.)

(If any time-critical medication information is unavailable, state reason and plan to obtain prior to OR.)

Past Medical History

• [Primary organ failure etiology]
• [Cardiovascular disease]
• [Pulmonary disease]
• [Diabetes mellitus and control]
• [Thromboembolic history/coagulopathy]
• [Chronic infections or colonization]
• [Malignancy history with status and treatment dates]
• [Prior transplants and graft outcomes]
• [Other comorbidities relevant to perioperative risk]

Past Surgical History

• [Abdominal surgeries with approximate dates]
• [Vascular access surgeries/procedures]
• [Cardiac procedures (PCI/CABG/valve)]
• [TIPS or portal interventions]
• [Thoracic surgeries]
• [Other operative history relevant to transplant]

Transplant History

• Listing date and status: [date]; [active / inactive / pending] (Reason if inactive.)
• Immunologic risk: [cPRA %]; [known DSAs]; [prior positive crossmatches] (Mark unknown if not available.)
• Sensitizing events since listing: [transfusions, pregnancy, infection, prior transplant]

Medications

• [Medication name – dose – route – frequency – last taken date/time]

(Use explicit notation for unknown last doses with reason and plan to verify. Flag time-critical medications including anticoagulants, antiplatelets, insulin, immunosuppressants.)

Allergies

• [Allergen – reaction type/severity (anaphylaxis / rash / intolerance)]

(Include contrast, latex, and chlorhexidine if relevant.)

Social History

• Primary caregiver/contact: [name, relationship, phone]
• Substance use: [alcohol / tobacco / other; last use if clinically relevant]

Physical Examination

• Vital signs: [BP, HR, RR, Temp, SpO2, weight; supplemental oxygen if applicable]
• General/Mental status: [appearance, orientation, capacity-relevant findings, asterixis if applicable]
• Cardiopulmonary: [heart sounds, murmurs, breath sounds, work of breathing]
• Abdomen: [distension, ascites, tenderness, surgical scars, hernias]
• Volume status: [peripheral edema, JVP if assessed]
• Skin/vascular access: [dialysis catheter / AVF / PD exit site inspection]
• Neurologic: [focal deficits; encephalopathy grade if relevant]

Data Reviewed

Resulted:

• CBC: [date/time] [key results]
• CMP: [date/time] [key results]
• Coagulation studies: [date/time] [PT/INR, aPTT]
• Type and screen/crossmatch: [date/time] [status/results]
• EKG: [date/time] [interpretation]
• Chest X-ray: [date/time] [impression]
• Pregnancy test: [date/time] [result] (If applicable.)
• OPTN-required infectious disease testing (HIV, HBV, HCV): [collection date/time] [results if available] (Must be collected before anastomosis per OPTN Policy 15.2.)
• Donor information from OPO: [ABO, PHS risk criteria, transmissible disease data, crossmatch status]

Pending/Ordered:

• [Labs pending with collection time]
• [Imaging/diagnostics pending]
• [Consults requested with urgency]

Assessment

[Synthesis paragraph] (3–6 sentences addressing: current appropriateness to proceed to transplant; highest-risk active issues that could delay or abort surgery such as infection concern, anticoagulation effects, hemodynamic instability, severe encephalopathy, hyperkalemia, missed dialysis.)

1. [Problem 1 – highest perioperative priority]: [brief assessment]
2. [Problem 2]: [brief assessment]
3. [Problem 3]: [brief assessment]

Plan

Perioperative/Transplant Plan

• Surgical plan and timing: [anticipated OR time; contingencies based on organ acceptance, crossmatch, recipient readiness]
• Disposition: [OR → ICU / stepdown / floor]
• Pre-op orders: [NPO status, pre-op labs, imaging, consults as indicated]
• Immunosuppression: [induction and maintenance per protocol; deviations with rationale]
• Antimicrobial prophylaxis: [perioperative antibiotics per protocol; CMV/PCP prophylaxis; modifications for allergies or colonization]
• VTE prophylaxis: [mechanical/chemical prophylaxis; anticoagulant hold/bridge strategy]
• Dialysis/volume management: [urgent dialysis timing relative to OR; paracentesis plan; encephalopathy management] (If applicable.)
• Glycemic management: [insulin strategy; hold SGLT2 inhibitors; perioperative targets] (If applicable.)
• Blood products: [type and cross status; transfusion consent status; anticipated needs]

Problem-Based Plan

(For each active problem: brief assessment and 1–4 actionable items. Prioritize transplant-readiness threats. Document rationale for proceeding vs delaying when issues are borderline.)

• [Problem 1]:
  • [Plan item]
• [Problem 2]:
  • [Plan item]

Consent and Counseling Summary

• Decision-maker and capacity: [patient has capacity / surrogate (name, relationship)]; [interpreter used with ID if applicable]; [capacity-relevant findings]
• Transplant surgery consent: [obtained / pending] [date/time]; [key risks, benefits, alternatives discussed]; [patient/surrogate understanding affirmed]
• Transmissible disease risk disclosure: [donor viral test results requiring consent: yes / no]; [consent obtained: date/time]; [PHS increased risk criteria disclosure: date/time] (If not obtained, document reason and escalation plan.)
• Blood transfusion consent: [obtained / pending] [date/time]

(Pre-transplant verification to be completed per institutional protocol and documented in intraoperative verification note.)

Missing Information Handling: Do not leave blanks for material items. Omit non-applicable organ modules entirely. For relevant but unavailable information, document as unknown with reason and plan to obtain. Use deferred with follow-up plan for time-sensitive items. Never infer absence of infection, medication timing, consent, or compatibility status beyond what is explicitly confirmed.