Transplant Selection Committee Presentation Note

Note Type: Selection Committee Presentation Note

Organ Program: [kidney / liver / heart / lung / multi-organ]

Conference Date: [Date]

Presenter/Author: [Name, credentials]

Attending of Record: [Name, credentials]

Referring Provider: [Name, affiliation]

Data Current Through: [Date/time of last update for labs, imaging, and consults]

Candidate Snapshot

• Age/Sex: [Age]; [Sex]
• Anthropometrics: Height [value]; Weight [value] (date); BMI [value]
• ABO Blood Type: [A / B / AB / O / Unknown—must verify prior to listing] (If unknown, duplicate in Outstanding Items; required for CMS compliance)
• Primary Diagnosis and Indication: [One-line summary of primary disease and transplant indication]
• Current Clinical Status: [inpatient / outpatient / ICU]; Supports: [dialysis modality / oxygen requirement / mechanical circulatory support / inotropes / none]
• Severity/Priority Metrics: [Organ-appropriate: MELD-Na with date (liver) / Dialysis vintage (kidney) / INTERMACS profile and hemodynamics (heart) / FEV1, DLCO, 6MWT (lung)]
• Current Listing Status: [Not listed / Listed active / Listed inactive / Prior delisting with reason and date]
• Transplant Type: [Deceased donor / Living donor / Either] (If living donor, note donor evaluation status)

Diagnosis and Trajectory

[Brief narrative summary of primary diagnosis, current disease phase, and rationale for transplant consideration at this time] (2–4 sentences; anchor events to time; avoid exhaustive H&P detail)

• Key Hospitalizations: [Date – reason – outcome]
• Major Turning Points: [Event and date, e.g., dialysis initiation, first decompensation, device implant]
• Trajectory: [improving / stable / declining] with supporting objective markers and dates
• Outside Records: [complete / incomplete] (Note gaps and implications if applicable)

Complications and Comorbidities

(Include only high-impact conditions affecting perioperative risk, immunosuppression tolerance, rehabilitation potential, or anatomic feasibility; note if any item represents a contraindication per program criteria)

• [Condition]: [active / controlled]; [objective evidence with date]; [relevance to transplant]
• [Condition]: [status]; [evidence with date]; [relevance]
• [Condition]: [status]; [evidence with date]; [relevance]

Psychosocial Readiness and Support

(Lead with bottom line for each domain, then supporting facts; distinguish objective data from interpretation; include dates; if any element is incomplete, state what is missing and plan to obtain)

Adherence

• Assessment: [Adherence concerns present / No adherence concerns / Indeterminate]
• Objective Data: [Dialysis attendance %, clinic attendance, medication refill gaps, device logs, INR variability with date ranges]
• Barriers/Context: [Transportation, health literacy, financial, or other contributing factors] (Separate observations from barriers)

Substance Use

• Assessment: [Meets program requirements / Active use / In treatment / Evaluation pending]
• History: [Tobacco / Alcohol / Other substances] – last use date or duration of abstinence
• Toxicology: [Test type, date, result] (Distinguish self-report from objective testing)
• Recovery Supports: [Treatment program, counseling, sponsor, monitoring plan]

Mental Health and Cognition

• Assessment: [Stable / Active symptoms impacting self-management / Cognitive concerns / Evaluation pending]
• Details: [Diagnoses, treatment status, cognitive assessment findings with dates]

Support and Caregiving Capacity

• Assessment: [Adequate caregiving plan / Gaps identified / Contingency plan needed]
• Functional Plan: Transportation [who/how]; Medication management [who/how]; Symptom monitoring [who/how]; Device care [who/how if applicable]
• Gaps and Mitigation: [Identified gaps and mitigation strategy with timeline]

Health Literacy and Communication

• Language/Interpreter: [Primary language; interpreter required yes/no]
• Transplant Understanding: [Demonstrated comprehension level; further education needed yes/no]
• Standardized Tool: [Tool name and score with date, e.g., SIPAT] (If used)

Outstanding Items and Barriers

Pending Evaluation Items

• [Test/consult/clearance] – [Required prior to listing / Can occur post-listing] – Owner: [name] – Target: [date] – Status: [scheduled / pending / delayed]
• [Test/consult/clearance] – [timing requirement] – Owner – Target – Status

Modifiable Barriers

• [Barrier] – Completion criteria: [specific measurable criteria] – Owner: [name] – Timeline: [date]
• [Barrier] – Completion criteria – Owner – Timeline

Nonmodifiable or Uncertain Barriers

• [Issue] – Impact on candidacy: [description] – Committee consideration needed: [yes / no]

(If requesting listing despite pending items, state risks of proceeding and justification)

Key Test Results

(Curate for selection relevance only; flag conflicting or outdated results; reference source notes rather than duplicating extensive detail)

Cardiac Workup

• Echo: [Date] – EF [value]%; [structural findings; RV function]
• Cardiac Cath: [Date] – [coronary anatomy; hemodynamics if applicable]
• Stress Test: [Date] – [modality; ischemia yes/no; METs achieved]

Pulmonary Function

• PFTs: [Date] – FEV1 [value]% pred; DLCO [value]% pred
• 6MWT: [Date] – [distance]; O2 requirement [value]

Malignancy Screening

• Colonoscopy: [Date] – [findings]
• Age-Appropriate Screening: [Tests completed with dates and findings]

Infectious Disease

• Serologies: [Date] – CMV [pos/neg]; EBV [pos/neg]; HBV [status]; HCV [status]; HIV [status]
• TB Screening: [Date] – [IGRA/PPD] – [result]

Immunologic

• CPRA: [Date] – [value]%
• HLA Antibodies/DSA: [Date] – [class I/II specifics; crossmatch implications]
• Sensitizing Events: [Transfusions, pregnancies, prior transplants with dates]

Presenter Assessment

(Synthesize earlier content; do not introduce new information; each bullet begins with decisive clause)

• Indication and Benefit: [Expected benefit from transplant tied to objective data]
• Key Risks: [Perioperative/medical risks and mitigation status]
• Psychosocial Readiness: [Supports adequate / Needs defined plan / Not adequate]
• Recommendation: [Meets criteria for listing / Borderline—requires optimization of (specific items) / Does not currently meet criteria because (reason)]

Committee Questions

1. [Does the candidate meet criteria for listing at this time?]
2. [If deferred, what specific conditions must be met and how will progress be measured?]
3. [Should listing be active vs inactive pending (specific item)?]
4. [Are there organ acceptance parameters or donor criteria to specify?]
5. [Is additional specialist or ethics input requested?]

Committee Decision

Decision: [Accept and list / Defer pending (specific items) / Decline / Remain inactive / Unable to determine—pending (items)]

Rationale:

• [Selection-relevant determinant]
• [Selection-relevant determinant]

Selection Criteria Applied: [Program criteria category/section reference] (Do not paste full policy text)

Action Items:

• [Action] – Owner: [name] – Due: [date] – Endpoint: [measurable criterion]
• [Action] – Owner – Due – Endpoint

Communication Plan: [Who will inform patient; who will inform referring provider; timeline per CMS requirements]