Transplant Candidate Surgical Evaluation Note

Note Type: Transplant Candidate Surgical Evaluation Note

Organ(s) Evaluated: [Organ(s) under consideration] — [single-organ / multi-organ]; [primary / re-transplant]

Date/Time of Service: [Date and time]

Encounter Setting: [inpatient / outpatient / telehealth] — [Location]

Referring Provider: [Name and credentials] — [Reason for referral]

Participants: [Attending surgeon]; [Trainee(s) if any]; [APP(s) if any]; [Interpreter: yes/no, language if applicable]

History Sources: [Patient / caregiver / outside records / dialysis unit / device team / other]

Records Reviewed: [Local EHR modules]; [Outside PDF records]; [Imaging PACS studies]; [Transplant portal]; [Other]

Chief Concern and Consult Question

Chief concern: [One-line patient-centered statement]

Consult question: Assess operative feasibility and surgical risk for transplant listing.

Candidacy Summary

[3–5 sentence summary of disease severity, timing/why now, and the surgical bottom line. State feasibility in conditional terms based on current data.]

• Indication and urgency: [Primary indication] — [elective / time-sensitive / urgent]
• Major surgical risk drivers: [Top risk drivers tied to exam/imaging/history]
• Key technical findings: [Imaging modality, date]: [Concise transplant-relevant findings]
• Absolute contraindications present: [yes / no / uncertain] (If yes or uncertain, specify.)
• Listing readiness status: [ready / needs optimization / needs workup / not a candidate]
• Top pre-committee workup items: [Item 1]; [Item 2]; [Item 3]; [Additional items as needed]

History of Present Illness

[Underlying diagnosis and duration of organ failure; severity trajectory including decompensations, admissions, ICU stays, dates of mechanical support or dialysis initiation; prior interventions affecting surgical field or access with dates; current functional limitations with timeframe; bleeding/thrombosis history; infection history with dates. Use direct quotes only for decisional items such as willingness for high-risk donors or sobriety commitments.] (Organize chronologically; include specific dates for last hospitalization, last ICU stay, last transfusion, last dialysis.)

Transplant-Relevant History

Prior Transplant History

• [Prior organ transplant(s), date(s), major complications, rejection episodes, cause of graft failure]
• [Prior transplant surgeries impacting anatomy or re-entry considerations]

Surgical History

• [Prior abdominal operations and adhesion risk]
• [Prior thoracic operations including sternotomy or device placements]
• [Vascular operations or interventions with dates]
• [Access-related procedures with laterality and status]
• [Prior radiation therapy fields or complex/chronic wounds]

Key Comorbidities

(Include only conditions impacting operative risk or candidacy.)

• Cardiac: [CAD / HF phenotype / valvular disease / arrhythmia devices with severity and dates]
• Pulmonary: [COPD / ILD / OSA / pulmonary hypertension / oxygen needs with baseline settings]
• Vascular: [PAD / carotid disease / aneurysms with severity]
• Metabolic: [Diabetes with end-organ damage / obesity with BMI]
• Neurologic: [Stroke/TIA history / cognitive impairment affecting rehab]
• Malignancy: [Type, stage, treatment dates, surveillance status]
• Infectious risks: [Chronic infections, colonization, source control status]

Medications and Allergies

• Anticoagulants/antiplatelets: [Agent(s), indication, last dose date/time, bleeding history]
• Vasoactive agents/inotropes: [Agent(s) and dose] (Include if applicable.)
• Immunosuppression: [Current regimen] (Include if re-transplant candidate.)
• Allergies: [Allergen — reaction type and severity; include contrast allergy if present]

Social and Adherence Snapshot

• Tobacco/vaping: [never / former / current] — [pack-years]; [quit date if former]
• Alcohol: [current / remote / none]; [treatment participation if applicable]; [sobriety duration or state "unknown"]
• Substances: [current / remote / none]; [treatment participation]; [toxicology if available]
• Support system: [Primary caregiver availability, transportation, distance to center]
• Housing stability: [stable / unstable / uncertain]
• Health literacy and barriers: [Language; interpreter needs; cognition; other barriers]
• Adherence indicators: [Dialysis attendance; appointment follow-through; medication adherence] (Document uncertainty if unclear.)
• Psychosocial evaluation status: [completed with date / pending / not yet scheduled]

Functional Status and Frailty

• Baseline function: [independent / assisted] — [ADLs/IADLs details]
• Mobility: [Gait aids]; [stairs]; [sit-to-stand performance]
• Exercise tolerance: [Distance/time]; [oxygen use]; [METs if known]
• Falls: [Number and timeframe]
• Nutrition/sarcopenia: [Unintentional weight loss % over timeframe]; [intake quality]; [muscle wasting on exam or imaging]
• Frailty assessment: [Tool name] — [Score/interpretation] — [Date] (If not yet performed, state "not yet assessed" and include in workup.)

Physical Examination

(If telehealth encounter, explicitly document elements not assessed.)

• Vitals: [BP]; [HR]; [RR]; [Temp]; [SpO2 on room air or device]; [Height]; [Weight]; [BMI]
• General: [Appearance; sarcopenia; work of breathing]
• Cardiovascular: [Murmurs]; [volume status]; [perfusion]; [device sites if present]
• Pulmonary: [Effort]; [baseline saturation and oxygen device]; [auscultation findings]
• Abdomen: [Scars]; [hernias]; [ascites]; [stomas]; [tenderness]; [surgical field complexity]
• Extremities/Vascular: [Pulses]; [edema]; [amputations]; [access sites and patency]
• Neurologic: [Gross deficits impacting rehab/participation]
• Skin/Wounds: [Ulcers]; [infection signs]; [frailty markers]

Data Review

Laboratory Trends

(Include dates for all values.)

• [Renal function markers]
• [Hepatic function markers]
• [CBC]
• [Coagulation profile]
• [Relevant serologies]
• [Nutritional markers if applicable]
• [Sensitization/immunology markers if applicable]
• ABO/Rh determination: [Type] — [confirmed with date / pending confirmation / unknown]
• [Last transfusion date and product type if applicable]

Cardiopulmonary Testing

(Include dates for all studies.)

• [Echocardiogram — date — key findings]
• [Right/left heart catheterization — date — hemodynamics summary]
• [Stress testing/CPET — date — summary]
• [PFTs/ABG — date — summary]
• [Device interrogation — date — summary] (Include if pacemaker/ICD/LVAD present.)

Screening Status

• Cancer screenings: [complete / pending / abnormal — specify]
• Dental clearance: [complete / pending]
• Infectious disease evaluation: [complete / pending]
• Vaccination review: [complete / pending]

Imaging Review

(If imaging not available or insufficient, state: "Unable to determine feasibility—imaging pending/insufficient.")

• [Modality and body region]: [Date] — [Personally reviewed by surgeon / Report only]
  • Key findings: [Arterial inflow options/quality; venous outflow options/patency; prior grafts/shunts/conduits; space constraints; abdominal wall issues; likely anastomosis targets with laterality/approach]
  • Limitations: [Non-contrast / incomplete arterial phase / motion artifact / none]

(Repeat for each relevant imaging study.)

Surgical and Technical Assessment

Proposed Operative Strategy

• Incision and approach: [Standard / alternative — specify]
• Additional procedures anticipated: [Endarterectomy / vascular reconstruction / hernia repair / redo sternotomy strategy / none / other]
• Blood loss and transfusion considerations: [Expected blood loss risk; product availability; cell saver; coagulopathy management]
• Postoperative considerations: [ICU level of care; extubation risk; hemodynamic monitoring; anticipated supports]

Technical Risk Drivers

• [Risk driver tied to specific imaging/history/exam finding]
• [Additional risk drivers as applicable]

Alternative Pathways

• Staged optimization needs: [Prehabilitation / nutrition / weight loss / smoking cessation / none]
• Multi-organ consideration: [Single-organ appropriate / multi-organ consideration with rationale]
• Alternative/bridge therapies: [Options if current surgical risk prohibitive]

Contraindications and Barriers

Potential Contraindications

• [Program-defined absolute contraindication] — [present / absent / uncertain]
• [Relative or high-risk feature] — [severity]

(List additional contraindications as applicable.)

Modifiable Barriers and Optimization Plan

• [Barrier] — [Actionable plan] — [Responsible party] — [Target timeframe]

(List additional barriers as applicable.)

Assessment and Plan

Overall impression: Surgical candidacy is [acceptable / high-risk / uncertain / not acceptable] pending [key item(s)].

(Address applicable problems from the list below in problem-oriented format. Omit problems that do not apply.)

• [Problem]
  • Status: [Current status and severity]
  • Impact on transplant surgery: [How this affects operative planning or candidacy]
  • Plan: [Required workup or intervention]
  • Responsible: [Service or person responsible]

(Common problem categories: primary organ failure indication/timing; cardiac risk; pulmonary risk; vascular access feasibility; surgical field complexity; frailty/nutrition/prehabilitation; infection risk/source control; malignancy surveillance; anticoagulation/bleeding risk.)

Required Workup Before Selection Decision

• Completed: [List with dates]
• Pending (ordered): [List with expected completion]
• Pending (not yet ordered): [List with responsible party]
• Abnormal requiring action: [Item and planned action]
• Outside records requested: [List and request dates]

Overall readiness status: [Green — complete / Yellow — minor items pending / Red — major barrier]

Surgical Recommendation

[Recommend proceed to committee for listing / Recommend proceed with minor contingencies (specify) / Defer listing decision pending workup completion / Do not recommend listing — (state reasons and whether modifiable)]

Selection meeting presentation: [yes / no]. Additional subspecialty input needed: [vascular surgery / cardiothoracic surgery / plastics / none / other].

Education and Consent Status

• Education provided today: [Procedure overview / surgical risks / transfusion / expected hospitalization / long-term follow-up]
• Alternatives discussed: [Medical management / palliative options / device support / dialysis / other]
• Patient questions and understanding: [Questions addressed; understanding demonstrated: yes/no]
• Transplant education module: [completed / pending per coordinator workflow]
• Surgical consent: [To be obtained per workflow / obtained — date]
• Special donor considerations discussed: [Expanded-risk donors / specific donor profiles — discussed / not discussed]

Communication and Notification

• Referring team notification: [Who; when; method] — [Documentation location]
• Patient/caregiver notification: [Who; when; method] — [Documentation location]
• Selection decision status: [Decision made — details / pending]
• Patient notification when decision rendered: [Notified — date/time/method / pending notification / not applicable]