9 Heart Transplant Recipient Follow Up 1-5 Year_Form.xlsx

TRF - Heart - Adult
Fields to be completed by members					Fields to be completed by members
Form Section	Field label	Notes		Form Section	Field label	Notes
1-Recipient Information	Organ Type	Display Only - Cascades from Database		1-Recipient Information	Organ Type	Display Only - Cascades from Database
1-Recipient Information	Follow up code	Display Only - Cascades from Database		1-Recipient Information	Follow up code	Display Only - Cascades from Database
1-Recipient Information	Recipient First Name	Display Only - Cascades from TCR		1-Recipient Information	Recipient First Name	Display Only - Cascades from TCR
1-Recipient Information	Recipient Last Name	Display Only - Cascades from TCR		1-Recipient Information	Recipient Last Name	Display Only - Cascades from TCR
1-Recipient Information	Recipient Middle Initial	Display Only - Cascades from TCR		1-Recipient Information	Recipient Middle Initial	Display Only - Cascades from TCR
1-Recipient Information	SSN	Display Only - Cascades from TCR		1-Recipient Information	SSN	Display Only - Cascades from TCR
1-Recipient Information	HIC	Display Only - Cascades from TCR		1-Recipient Information	HIC	Display Only - Cascades from TCR
1-Recipient Information	Previous Follow-Up	Display Only - Cascades from prior TRF		1-Recipient Information	Previous Follow-Up	Display Only - Cascades from prior TRF
1-Recipient Information	DOB	Display Only - Cascades from TCR		1-Recipient Information	DOB	Display Only - Cascades from TCR
1-Recipient Information	Gender	Display Only - Cascades from TCR		1-Recipient Information	Gender	Display Only - Cascades from TCR
1-Recipient Information	Tx Date	Display Only - Cascades from Database		1-Recipient Information	Tx Date	Display Only - Cascades from Database
1-Recipient Information	Previous Px Stat Date	Display Only - Cascades from prior TRF		1-Recipient Information	Previous Px Stat Date	Display Only - Cascades from prior TRF
1-Recipient Information	Transplant Discharge Date			1-Recipient Information	Transplant Discharge Date
1-Recipient Information	Zip Code			1-Recipient Information	Zip Code
2-Provider Information	Recipient Center Type	Display Only - Cascades from TCR		1-Recipient Information	Previous Px Stat Date	Display Only - Cascades from prior TRF
2-Provider Information	Recipient Center	Display Only - Cascades from TCR		2-Provider Information	Recipient Center Type	Display Only - Cascades from TCR
2-Provider Information	Followup Center Code	Display Only - Cascades from Database		2-Provider Information	Recipient Center	Display Only - Cascades from TCR
2-Provider Information	Followup Center Type	Display Only - Cascades from Database		2-Provider Information	Followup Center Code	Display Only - Cascades from Database
2-Provider Information	Physician Name			2-Provider Information	Followup Center Type	Display Only - Cascades from Database
2-Provider Information	NPI#			2-Provider Information	Physician Name
2-Provider Information	Follow-up Care Provided By			2-Provider Information	NPI#
2-Provider Information	Follow-up Care Provided By//Specify			2-Provider Information	Follow-up Care Provided By
3- Donor Information	UNOS Donor ID #	Display Only - Cascades from Database		2-Provider Information	Follow-up Care Provided By//Specify
3- Donor Information	Donor Type	Display Only - Cascades from Database		3- Donor Information	UNOS Donor ID #	Display Only - Cascades from Database
3 - Donor Information	OPO	Display Only - Cascades from feedback		3- Donor Information	Donor Type	Display Only - Cascades from Database
4-Patient Status	Date: Last Seen, Retransplanted or Death			3- Donor Information	OPO	Display Only - Cascades from feedback
4-Patient Status	Patient Status			4-Patient Status	Date: Last Seen, Retransplanted or Death
4-Patient Status	Primary Cause of Death			4-Patient Status	Patient Status
4-Patient Status	Primary Cause of Death//Specify			4-Patient Status	Primary Cause of Death
4-Patient Status	Contributory Cause of Death	Not required		4-Patient Status	Primary Cause of Death//Specify
4-Patient Status	Contributory Cause of Death//Specify	Not required		4-Patient Status	Contributory Cause of Death	Not required
4-Patient Status	Contributory Cause of Death	Not required		4-Patient Status	Contributory Cause of Death//Specify	Not required
4-Patient Status	Contributory Cause of Death//Specify	Not required		4-Patient Status	Contributory Cause of Death	Not required
4-Patient Status	Has the patient been hospitalized since the last patient status date			4-Patient Status	Contributory Cause of Death//Specify	Not required
4-Patient Status	Hospitalized for Rejection			4-Patient Status	Has the patient been hospitalized since the last patient status date
4-Patient Status	Hospitalized for Infection			4-Patient Status	Hospitalized for Rejection
4-Patient Status	Functional Status			4-Patient Status	Hospitalized for Infection
4-Patient Status	Working for income			4-Patient Status	Functional Status
4-Patient Status	Primary Insurance at Follow-up			4-Patient Status at Time of Follow-Up	Cognitive Development
4-Patient Status	Primary Source of Payment, Specify			4-Patient Status at Time of Follow-Up	Motor Development
5-Clinical Information	Heart Graft Status			4-Patient Status	Working for income
5-Clinical Information	Heart Date of Graft Failure			4-Patient Status	Academic Progress
5-Clinical Information	Heart Primary Cause of Graft Failure			4-Patient Status	Academic Activity Level
5-Clinical Information	Heart Primary Cause of Graft Failure//Other, Specify			4-Patient Status	Primary Insurance at Follow-up
5-Clinical Information	HIV Serology			4-Patient Status	Primary Source of Payment, Specify
5-Clinical Information	HIV NAT			5-Clinical Information	Date of Measurement
5-Clinical Information	HbsAg			5-Clinical Information	Height
5-Clinical Information	HBV DNA			5-Clinical Information	Height//Status	Value or status is reported, not both
5-Clinical Information	HBV Core Antibody			5-Clinical Information	Height Percentile	Calculated for display only
5-Clinical Information	HCV Serology			5-Clinical Information	Weight
5-Clinical Information	HCV NAT			5-Clinical Information	Weight//Status	Value or status is reported, not both
5-Clinical Information	Ejection Fraction			5-Clinical Information	Weight Percentile	Calculated for display only
5-Clinical Information	Heart: Ejection Fraction//Status	Value or status is reported, not both		5-Clinical Information	BMI	Display Only - Cascades from Database
5-Clinical Information	Pacemaker			5-Clinical Information	BMI	Calculated for display only
5-Clinical Information	Coronary Artery Disease			5-Clinical Information	Heart Graft Status
5-Clinical Information	New diabetes onset between last follow-up to the current follow-up			5-Clinical Information	Heart Date of Graft Failure
5-Clinical Information	Diabetes: If Yes, Insulin Dependent			5-Clinical Information	Heart Primary Cause of Graft Failure
5-Clinical Information	Most Recent Serum Creatinine			5-Clinical Information	Heart Primary Cause of Graft Failure//Other, Specify
5-Clinical Information	Most Recent Serum Creatinine//Status	Value or status is reported, not both		5-Clinical Information	Most Recent Anti-A Titer
5-Clinical Information	Chronic Dialysis			5-Clinical Information	Most Recent Anti-A Titer//Sample Date
5-Clinical Information	Renal Tx since Thoracic Tx			5-Clinical Information	Most Recent Anti-B Titer
5-Clinical Information	Did patient have any acute rejection episodes during the follow-up period			5-Clinical Information	Most Recent Anti-B Titer//Sample Date
5-Clinical Information	Post Transplant Malignancy			5-Clinical Information	HIV Serology
5-Clinical Information	Donor Related			5-Clinical Information	HIV NAT
5-Clinical Information	Recurrence of Pre-Tx Tumor			5-Clinical Information	HbsAg
5-Clinical Information	De Novo Solid Tumor			5-Clinical Information	HBV DNA
5-Clinical Information	De Novo Lymphoproliferative disease and Lymphoma	Display Only - Cascades from Database		5-Clinical Information	HBV Core Antibody
7-Immunosuppressive Information	Were any medications given during the follow-up period for maintenance	Display Only - Cascades from Database		5-Clinical Information	HCV Serology
7-Immunosuppressive Information	Previous Validated Maintenance Follow-Up Medications	Display Only - Cascades from Database		5-Clinical Information	HCV NAT
7- Immunosupression Other	immunosuppression medication			5-Clinical Information	Ejection Fraction
7- Immunosupression Other	immunosuppression medication indication			5-Clinical Information	Heart: Ejection Fraction//Status	Value or status is reported, not both
				5-Clinical Information	Shortening Fraction
	Public Burden Statement			5-Clinical Information	Shortening Fraction://Status	Value or status is reported, not both
				5-Clinical Information	Pacemaker
				5-Clinical Information	Coronary Artery Disease Since Last Follow Up
				5-Clinical Information	Did patient have any acute rejection episodes during the follow-up period
				5-Clinical Information	New diabetes onset between last follow-up to the current follow-up
				5-Clinical Information	Diabetes: If Yes, Insulin Dependent
				5-Clinical Information	Most Recent Serum Creatinine
				5-Clinical Information	Most Recent Serum Creatinine//Status	Value or status is reported, not both
				5-Clinical Information	Chronic Dialysis
				5-Clinical Information	Renal Tx since Thoracic Tx
				5-Clinical Information	Post Transplant Malignancy
				5-Clinical Information	Donor Related
				5-Clinical Information	Recurrence of Pre-Tx Tumor
				5-Clinical Information	De Novo Solid Tumor
				5-Clinical Information	De Novo Lymphoproliferative disease and Lymphoma
				5-Clinical Information	Diabetes onset during the follow-up period
				5-Clinical Information	If yes, insulin dependent
				7-Immunosuppressive Information	Were any medications given during the follow-up period for maintenance	Display Only - Cascades from Database
				7-Immunosuppressive Information	Previous Validated Maintenance Follow-Up Medications
				7- Immunosupression Other	immunosuppression medication
				7- Immunosupression Other	immunosuppression medication indication
					Public Burden Statement