Transplant Selection Committee Decision Note

Patient Name: [Patient full name]
MRN: [Medical record number]
DOB: [DOB]
Organ/Program: [Organ/program name]
Meeting Date/Time: [Date and time]
Case Presented By: [Presenter name/role]

Decision Summary

Final Determination: [Approved for Listing / Deferred / Declined / Removed from Waiting List / Status Changed]

Listing Disposition: [Active / Inactive / Not applicable]
(If Approved: specify active vs. inactive and, if inactive, give reason and activation trigger. If Deferred: explicitly list what is missing and why it matters to candidacy. If Declined: specify absolute vs. conditional/re-referrable and outline the pathway for reconsideration. If Status Changed: specify prior status, new status, and reason.)

Decision Rationale:

• [Primary driver of decision—highest impact first]
• [Additional driver] (Include up to 3 additional drivers as applicable)

Criteria Reference: [Program selection criteria title / version / date]
Applicability: [Meets criteria / Meets with contingencies / Variance applied]

Variance Justification: [Rationale for variance and specific monitoring/mitigation plan] (Include only if variance applied)

Re-review Date/Trigger: [Date or specific trigger condition] (Required if Deferred or Conditionally Approved/Inactive)

Candidate Synopsis

[One concise paragraph summarizing: primary diagnosis/indication and severity; comorbidities materially affecting candidacy; functional status; key psychosocial considerations (supports, adherence behaviors, substance use status) using person-first, factual language; living donor availability if relevant. Reference prior evaluation notes for detail rather than restating.] (3–6 sentences)

Evaluation Clearances

(List only domains that were evaluated for this candidate. For each, include status tag and 1–2 bullets of key findings. If pending, specify what is missing, why it matters, owner, and due date.)

• Medical/Organ-Specific: [Cleared / Cleared with Contingencies / Not Cleared / Pending]
  • [Key findings impacting candidacy]
  • [Pending item with owner and due date] (If applicable)
• Surgical: [Cleared / Cleared with Contingencies / Not Cleared / Pending]
  • [Operability assessment and pertinent anatomic considerations]
• Cardiology/Pulmonology: [Cleared / Cleared with Contingencies / Not Cleared / Pending]
  • [Cardiopulmonary risk assessment highlights]
• Infectious Disease: [Cleared / Cleared with Contingencies / Not Cleared / Pending]
  • [Immunization/serology/infection risk summary]
• Oncology: [Cleared / Cleared with Contingencies / Not Cleared / Pending]
  • [Malignancy history and disease-free interval]
• Pharmacy: [Cleared / Cleared with Contingencies / Not Cleared / Pending]
  • [Medication reconciliation and immunosuppression considerations]
• Nutrition: [Cleared / Cleared with Contingencies / Not Cleared / Pending]
  • [Nutritional status and modifiable risks]
• Social Work: [Cleared / Cleared with Contingencies / Not Cleared / Pending]
  • [Care partner/support plan; barriers identified with objective anchors and mitigation]
• Psychiatry/Psychology: [Cleared / Cleared with Contingencies / Not Cleared / Pending]
  • [Mental health/substance use assessment; treatment/monitoring plan if applicable]
• Financial/Insurance: [Cleared / Cleared with Contingencies / Not Cleared / Pending]
  • [Coverage status and pending authorizations]
• Dental: [Cleared / Cleared with Contingencies / Not Cleared / Pending]
  • [Infection risk and clearance status]

Committee Discussion

(3–6 bullets summarizing major points; include dissent and resolution if present)

• [Major discussion point regarding risk/benefit considerations]
• [Additional discussion point]
• [Dissenting viewpoint and how resolved] (If applicable)

Contingencies and Follow-up Tasks

(Each task must be specific and measurable. Specify whether required for listing vs. activation if program uses inactive listing.)

Task	Owner	Due Date	Evidence Required	Status
[Required for Listing / Required for Activation] [Specific, measurable task]	[Name/Role]	[Date]	[Document/result needed]	[Open / In progress / Complete]
[Required for Listing / Required for Activation] [Specific, measurable task]	[Name/Role]	[Date]	[Document/result needed]	[Open / In progress / Complete]

Communication Plan

Patient Notification: [Yes / No / Attempted]; Method: [phone / portal / in-person / letter]; Date: [date]; Communicator: [name/role]
(If not yet informed, specify planned date and responsible party)

Written Notice Required: [Placement on waitlist / Evaluation complete but not listed / Removal from waitlist / Not required]
Sender: [name/role]; Deadline: [date]; Confirmation documented in: [EHR location]

Referring Provider Notification: [Notifier] will notify [referring provider] via [method] within [timeframe]
(For kidney candidates, include dialysis facility notification if applicable)

Attestation

This note summarizes the multidisciplinary selection committee discussion and final determination from [meeting date].

Author: [Name, credentials, role]
Signature: [e-signature/date-time]

Committee Chair/Medical Director Co-signature: [Name, credentials, role]
Signature: [e-signature/date-time]
(Include if required by local policy)