Transplant Surgery SOAP Note

Date/Time: [Date and time of note entry]

Setting: [inpatient / clinic] — [Service/Team]

POD / Transplant Day: [Postoperative day or transplant day]

Transplant Summary: [Organ] | [Transplant date] | [Donor type] | [Key serologies: CMV D/R, EBV D/R, HBV/HCV as relevant] | [Induction agent if recent] | [Current maintenance immunosuppression regimen] | [Major early complications if ongoing]

Subjective

[Interval narrative: 1–2 sentences stating POD/transplant day, organ, and overnight events (inpatient) or interval events since last visit (clinic). State explicitly if no acute events.]

• Symptoms: [Graft and immunosuppression-relevant symptoms: pain, GI symptoms, fever/infection signs, CNI toxicity symptoms, volume-related symptoms]
• Medication adherence: [Adherence summary with concrete anchor—patient report, MAR, or pharmacy fill history] (Do not infer adherence without explicit verification.)
• Home/Ward monitoring: [Urine output, weights, glucose logs, drain outputs as relevant] (Omit if not applicable.)

Objective

Vitals: [Temp, HR, BP, RR, SpO2, weight trend, pain score as relevant]

I/O (24h): [Total in/out, net balance, urine output, drain outputs, dialysis UF if applicable] (Omit for clinic visits without relevant data.)

Lines/Drains: (Include only if devices present; omit section entirely if none.)

• [Device type — location; day placed; indication; current status/output; removal plan or criteria]

Exam: [Focused exam with pertinent positives and negatives—general appearance; cardiovascular/respiratory; abdomen including graft area, wound, bruit/thrill; extremities; neurologic findings relevant to immunosuppression toxicity]

Labs/Studies: (Include only abnormal, trended, or decision-driving values with dates.)

• [Immunosuppressant trough level with collection timing, target, interpretation]
• [Organ function trend: renal function, LFTs, or organ-specific labs]
• [Infectious monitoring: viral loads, cultures with collection dates]
• [Imaging/biopsy results with key findings]

Medications: [Current immunosuppression with doses and last administration time; infection prophylaxis with start and intended stop dates; other decision-driving medications] (Reference full reconciled list elsewhere.)

Assessment

[One-liner: POD/transplant day, organ, graft trajectory [improving / stable / worsening] with key objective trend, top 1–3 active issues]

Graft status: [Organ-specific objective anchors—creatinine and UOP for kidney; LFTs and Doppler for liver; hemodynamics and echo for heart; oxygenation and CXR for lung]

[Problem 1] — [improving / stable / worsening]

[Brief assessment with key evidence driving management]

[Problem 2] — [improving / stable / worsening]

[Additional problems in order of severity and transplant relevance] (Include only active problems.)

Plan

(Organize by problem. For each, include monitoring, diagnostics, therapeutic changes with rationale, and coordination as applicable. Use "Pending," "Not obtained today," or "Due [date]" where information is unavailable. Do not infer absence of infection or rejection without explicit verification.)

[Problem 1]

• Monitoring: [Parameters, cadence, escalation triggers]
• Diagnostics: [Tests ordered and timing]
• Therapy: [Changes with doses and rationale]
• Coordination: [Consults, handoffs, education, access checks]

[Problem 2]

• Monitoring: [Parameters, cadence, escalation triggers]
• Diagnostics: [Tests ordered and timing]
• Therapy: [Changes with doses and rationale]
• Coordination: [Consults, handoffs, education, access checks]

Transplant-Critical Domains

(Address each relevant domain within the problem list above or summarize status here. Omit domains that do not apply.)

• Immunosuppression: [Current regimen; target level; today's level with interpretation; dose changes and rationale; next level timing; drug interactions]
• Rejection surveillance: [Current modality; most recent result; next due date or biopsy trigger]
• Infection: [Prophylaxis strategy with stop dates; active infections with antimicrobials, duration, de-escalation plan; interaction check]
• Lines/Drains/Wounds: [Removal criteria; output thresholds; wound care plan]
• Disposition: [Discharge readiness criteria; PT/OT status; medication access confirmed; follow-up labs and appointments; education completed or pending]