Transplant Surgery Inpatient Consult Note

Date/Time of Encounter: [Date and time]

Author: [Name, role, service]

Patient: [Name, MRN, DOB, location]

Requesting Service/Clinician: [Service and clinician name]

Consult Urgency: [routine / urgent / emergent]

Consult Scope: [recommendations only / co-management / transfer of care]

Information Sources: [Sources: patient, family, chart, outside records, interpreter] (Note significant limitations to history or data.)

Consult Context: [pre-transplant evaluation / post-transplant complication / perioperative donor-offer evaluation]

Consult Request

Reason for Consult: [Clinical question in requesting team's terms] (Single sentence.)

Clinical Summary: [One-liner: patient identifier, transplant status/organ, acuity, key physiology, suspected problem]

Consultant Deliverables: [What this consult will provide: diagnostic synthesis, operative risk assessment, donor/recipient considerations, immediate priorities and contingency planning]

History

History Source and Limitations: [Who provided history; collateral sources; records reviewed; any limitations such as encephalopathy, intubation, delirium, language barrier]

History of Present Illness: [Chronological narrative anchored to consult question, including admission timeline, key turning points, acuity markers, and transplant-specific triggers] (Use direct quotes only for goals of care or high-stakes statements.)

Transplant History (Include for post-transplant consults; omit if not applicable.)

• Organ(s) and Date(s): [Organ(s), transplant date(s)]
• Donor Type: [living / deceased, DBD / DCD]
• Induction Regimen: [Agents and doses]
• Maintenance Immunosuppression: [Current agents with doses and timing of last dose]
• Prophylaxis: [CMV, PJP, fungal agents and duration]
• Recipient Serologies: [CMV IgG, EBV IgG status]
• Prior Complications: [Rejection episodes, vascular/biliary/ureteral issues, infections, malignancy]
• Baseline Graft Function: [Most recent stable creatinine, bilirubin, or organ-specific markers]
• Surgical Anatomy: [Prior operations, vascular reconstructions, stomas, drains, stents]

(If information is unknown, document "unknown—records requested" rather than leaving blank.)

Candidacy Evaluation (Include only for pre-transplant evaluation consults; omit otherwise.)

• Primary Diagnosis and Severity: [Diagnosis and severity markers for transplant indication]
• Active Infection/Sepsis: [present / absent / unknown / pending] — [supporting facts]
• Active Malignancy: [present / absent / unknown / pending] — [supporting facts]
• Substance Use Disorder: [present / absent / unknown / pending] — [type, abstinence duration, last use]
• Psychiatric Illness Affecting Adherence: [present / absent / unknown / pending] — [supporting facts]
• Medication Adherence History: [adequate / concerns / unknown] — [supporting facts]
• Severe Cardiopulmonary Comorbidity: [present / absent / unknown / pending] — [supporting facts]
• Frailty/Malnutrition: [present / absent / unknown / pending] — [assessment or indicators]
• Social Situation Barriers: [present / absent / unknown / pending] — [caregiver, housing, access to care]

(Do not infer absence unless explicitly assessed.)

Past Medical/Surgical History: [Focused items impacting operative risk and candidacy; include relevant infections and cancer history with recurrence status]

Medications: [Immunosuppressants with doses and missed doses; antimicrobials with start dates and indications; anticoagulation/antiplatelets with last dose timing; nephrotoxic/hepatotoxic agents]

Allergies: [Allergen — reaction type and severity] (Distinguish intolerance from anaphylaxis.)

Social History: [Substance use with type, quantity, last use; support system and identified caregiver; housing stability; barriers to post-transplant care] (Include for candidacy consults. Avoid stigmatizing language.)

Physical Examination

Vitals and Clinical Status: [Current vitals with notable 24-hour trends; respiratory support level; vasopressor requirements; renal replacement therapy; recent transfusions; drain outputs]

• General: [Distress, jaundice, cachexia, edema]
• Cardiovascular: [Perfusion, heart sounds, edema]
• Respiratory: [Work of breathing, oxygenation, breath sounds]
• Abdomen: [Incisions, tenderness, peritonitis signs, distension, ascites]
• Surgical Sites/Drains/Stomas: [Erythema, drainage, fluctuance, output amount and quality]
• Vascular Access: [Dialysis catheter, fistula, central lines]
• Neurologic: [Mentation, encephalopathy, focal deficits]

(Omit systems not examined.)

Diagnostic Data

(Include only data actually reviewed. Summarize salient results; avoid full tables.)

• Laboratory Studies: [CBC with differential, CMP, coagulation, lactate, blood gas; transplant-specific labs including drug levels, bilirubin or creatinine trends, LFT pattern, troponin/BNP]
• Microbiology: [Cultures and PCRs with collection times and antibiotic exposure context]
• Imaging: [Study, date, and interpretation] (Clearly distinguish your interpretation from radiology impression.)
• Procedural/Pathology Data: [Biopsy results, operative reports, endoscopy findings]
• Cardiopulmonary Testing: [ECG, echocardiogram, PFTs, catheterization data relevant to operative risk]
• Transplant Immunology: [ABO type with verified source, HLA/DSA, crossmatch status, PRA] (Document from verified sources only; do not infer.)
• Pending Critical Tests: [Test — expected availability — interim plan]

Assessment

(Problem-oriented, ordered by acuity. For each problem include working diagnosis, key evidence, differential if unclear, severity and trajectory, risk implications, and decision points.)

Primary Transplant Problem

[Working diagnosis with key supporting evidence, severity, and trajectory]

• Differential: [Ranked differential with brief rationale] (Include if diagnosis uncertain.)
• Risk Implications: [Operative, graft, and mortality risk]
• Key Decision Points: [What will change management]

Additional Problems

[Problem label]: [Working diagnosis, evidence, differential, risks, decision points]

(Repeat for each additional problem.)

Candidacy Summary (Include only for pre-transplant evaluation consults.)

• Indication: [met / not met / uncertain] — [supporting facts]
• Contraindications: [identified / none evident / uncertain] — [details]
• Operative Feasibility: [Anatomic and technical considerations]
• Physiologic Reserve: [Hemodynamics, respiratory status, renal support, frailty]
• Psychosocial Readiness: [Summary]
• Bottom Line: [appropriate to proceed / high-risk with barriers requiring remediation / not a candidate] — [specific reasons]

Post-Transplant Complication Framework (Include only for post-transplant consults.)

• Technical/Surgical: [Bleeding, leak, obstruction, wound]
• Vascular: [Thrombosis, stenosis, ischemia]
• Anastomotic: [Organ-specific complications]
• Allograft Dysfunction Etiologies: [Rejection, drug toxicity, ischemia-reperfusion, recurrent disease, infection]
• Infectious Syndromes: [Suspected or confirmed infections with timing and risk context]
• Medication Toxicity/Interactions: [Concerns and rationale]

Operative Risk Assessment (Include when surgery or listing is under consideration.)

• Cardiovascular Risk and Functional Status: [Assessment]
• Respiratory Risk: [Assessment]
• Bleeding Risk/Coagulopathy: [Assessment]
• Renal Status: [Renal function and RRT implications]
• Nutrition/Frailty: [Assessment if evaluated]
• Immunologic/Infectious Considerations: [DSA, crossmatch, active or past infections]

Plan

(Problem-based with actions now, monitoring parameters, escalation criteria, contact information, and time horizon. Use if/then contingencies for decision points.)

[Problem 1]

• Diagnostic Plan: [Specific tests, timing, and how results will change management; note independent imaging review or over-read requests]
• Therapeutic Plan: [Antimicrobials with indication, target duration, de-escalation triggers; immunosuppression adjustments with monitoring; fluids, vasopressors, blood products with goals; anticoagulation and DVT prophylaxis with rationale; drains, stents, tubes with thresholds and removal criteria]
• Contingencies: [If/then branches and escalation triggers]

[Problem 2]

• Diagnostic Plan: [Tests, timing, management implications]
• Therapeutic Plan: [Interventions with goals and monitoring]
• Contingencies: [Escalation triggers and alternative pathways]

(Repeat for additional problems as needed.)

Donor/Recipient Considerations (Include for organ offer, imminent transplant, or donor-derived risk scenarios.)

• ABO/Compatibility Verification: [Documented from verified sources]
• Crossmatch/DSA Status: [Current status]
• Infectious Risk Counseling: [What was discussed, with whom, when]
• Post-Transplant Surveillance Plan: [If indicated]

Disposition: [Recommended level of care; transplant surgery follow-up frequency or sign-off; post-discharge follow-up needs]

Communication and Coordination

• Primary Team Contacted: [Name and role] at [time] — [key recommendations communicated]
• Patient/Family Communication: [Summary of discussions regarding surgery, candidacy decisions, or high-risk donor counseling]
• Other Services Coordinated: [Transplant coordinator, social work, pharmacy, infectious disease, anesthesia, ICU, interventional radiology, subspecialties]
• Critical Information Gaps: [What is missing, why, and steps to obtain it]

(This section is required for all consults.)