25 Liver Transplant Recipient Registration_Form.xlsx

TRR - Liver - Adults
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	Display Only - Cascades from TCR		1- Recipient Information	Organ	Display Only - Cascades from TCR
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	Not required		1- Recipient Information	Recipient Middle Initial	Not required
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	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 feedback		1- Recipient Information	Tx Date	Display Only - Cascades from feedback
1- Recipient Information	State of Permanent Residence			1- Recipient Information	State of Permanent Residence
1- Recipient Information	Permanent Zip			1- Recipient Information	Permanent Zip
2 - Provider Information	Recipient Center Code	Display Only - Cascades from TCR		2 - Provider Information	Recipient Center Code	Display Only - Cascades from TCR
2 - Provider Information	Recipient Center Type	Display Only - Cascades from TCR		2 - Provider Information	Recipient Center Type	Display Only - Cascades from TCR
2 - Provider Information	Surgeon Name			2 - Provider Information	Surgeon Name
2 - Provider Information	NPI#			2 - Provider Information	NPI#
3 - Donor Information	UNOS Donor ID #	Display Only - Cascades from feedback		3 - Donor Information	UNOS Donor ID #	Display Only - Cascades from feedback
3 - Donor Information	Donor Type	Display Only - Cascades from feedback		3 - Donor Information	Donor Type	Display Only - Cascades from feedback
3 - Donor Information	OPO	Display Only - Cascades from feedback		3 - Donor Information	OPO	Display Only - Cascades from feedback
4 - Patient Status	Primary Diagnosis			4 - Patient Status	Primary Diagnosis
4 - Patient Status	Primary Diagnosis//Specify			4 - Patient Status	Primary Diagnosis//Specify
4 - Patient Status	Date: Last Seen, Retransplanted or Death			4 - Patient Status	Date: Last Seen, Retransplanted or Death
4 - Patient Status	Patient Status			4 - Patient Status	Patient Status
4 - Patient Status	Primary Cause of Death			4 - Patient Status	Primary Cause of Death
4 - Patient Status	Cause of Death//Specify			4 - Patient Status	Cause of Death//Specify
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	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	Date of Admission to Tx Center			4-Patient Status	Date of Admission to Tx Center
4-Patient Status	Date of Discharge from Tx Center			4-Patient Status	Date of Discharge from Tx Center
4-Patient Status	Patient on Life Support			4-Patient Status	Medical Condition at time of transplant
4-Patient Status	Ventilator			4-Patient Status	Patient on Life Support
4-Patient Status	Artificial Liver			4-Patient Status	Ventilator
4-Patient Status	Other Mechanism			4-Patient Status	Artificial Liver
4-Patient Status	Other Mechanism, Specify			4-Patient Status	Other Mechanism
4-Patient Status	Functional Status			4-Patient Status	Other Mechanism, Specify
4-Patient Status	Working for income			4-Patient Status	Functional Status
4-Patient Status	Primary Source of Payment			4-Patient Status	Working for income
4-Patient Status	Primary Source of Payment, Specify			4-Patient Status	Academic Progress
5- Pretransplant	Height			4-Patient Status	Academic Activity Level
5- Pretransplant	Height in Centimeters//Status	Value or status is reported, not both		4-Patient Status	Primary Source of Payment
5- Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only		4-Patient Status	Primary Source of Payment, Specify
5- Pretransplant	Weight			4-Patient Status	Cognitive Development
5- Pretransplant	Weight in Kilograms//Status	Value or status is reported, not both		4-Patient Status	Motor Development
5- Pretransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only		5- Pretransplant	Date of Measurement
5- Pretransplant	BMI	Display Only - Cascades from Database		5- Pretransplant	Height
5- Pretransplant	BMI://%ile	Calculated for display only		5- Pretransplant	Height in Centimeters//Status	Value or status is reported, not both
5- Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database		5- Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only
5- Pretransplant	Previous Transplant Date	Display Only - Cascades from Database		5- Pretransplant	Weight
5- Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database		5- Pretransplant	Weight in Kilograms//Status	Value or status is reported, not both
5- PreTransplant	HIV Serostatus			5- Pretransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only
5- PreTransplant	NAT HIV			5- Pretransplant	BMI	Display Only - Cascades from Database
5- PreTransplant	CMV Status			5- Pretransplant	BMI://%ile	Calculated for display only
6- PreTransplant	HBV Core Antibody			5- Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database
5- PreTransplant	HBV Surface Antibody Total			5- Pretransplant	Previous Transplant Date	Display Only - Cascades from Database
5- PreTransplant	HBV Core Antibody			5- Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database
5- PreTransplant	HBV Surface Antigen			5- PreTransplant	HIV Serostatus
5- PreTransplant	NAT HBV			5- PreTransplant	NAT HIV
5- PreTransplant	HCV Serostatus			5- PreTransplant	CMV Status
5- PreTransplant	NAT HCV			6- PreTransplant	HBV Core Antibody
5- PreTransplant	EBV Serostatus			5- PreTransplant	HBV Surface Antibody Total
6- PreTransplant	Has the recipient ever had a diagnosis of HCC?			5- PreTransplant	HBV Core Antibody
6-Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback		5- PreTransplant	HBV Surface Antigen
6-Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback		5- PreTransplant	NAT HBV
6-Transplant Procedure	Procedure Type	Display Only - Cascades from feedback		5- PreTransplant	HCV Serostatus
6-Transplant Procedure	Split Type			5- PreTransplant	NAT HCV
6-Transplant Procedure	Total Cold Ischemia Time (if pumped, include pump time)			5- PreTransplant	EBV Serostatus
6-Transplant Procedure	Total Cold Ischemia Time (if pumped, include pump time)://Status	Value or status is reported, not both		6- PreTransplant	Has the recipient ever had a diagnosis of HCC?
6-Transplant Procedure	Previous Abdominal Surgery			6-Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback
6-Transplant Procedure	Portal Vein Thrombosis			6-Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback
6-Transplant Procedure	Transjugular Intrahepatic Portacaval Stint Shunt			6-Transplant Procedure	Procedure Type	Display Only - Cascades from feedback
7- Post Transplant	Pathology Conf. Liver Diag. of Hospital Discharge			6-Transplant Procedure	Split Type
7- Post Transplant	If Other Pathology Conf. Liver Diag. of Hospital Discharge//Specify			6-Transplant Procedure	Total Cold Ischemia Time (if pumped, include pump time)
7- Post Transplant	Graft Status			6-Transplant Procedure	Total Cold Ischemia Time (if pumped, include pump time)://Status	Value or status is reported, not both
7- Post Transplant	Date of Graft Failure			6-Transplant Procedure	Previous Abdominal Surgery
7- Post Transplant	Primary Non-Function			6-Transplant Procedure	Portal Vein Thrombosis
7- Post Transplant	Hepatic Artery Thrombosis			6-Transplant Procedure	Transjugular Intrahepatic Portacaval Stint Shunt
7- Post Transplant	Other Vascular Thrombosis			7- Post Transplant	Pathology Conf. Liver Diag. of Hospital Discharge
7- Post Transplant	Hepatic outflow obstruction			7- Post Transplant	If Other Pathology Conf. Liver Diag. of Hospital Discharge//Specify
7- Post Transplant	Portal vein thrombosis			7- Post Transplant	Graft Status
7- Post Transplant	Diffuse Cholangiopathy			7- Post Transplant	Date of Graft Failure
7- Post Transplant	Hepatitis: DeNovo			7- Post Transplant	Primary Non-Function
7- Post Transplant	Hepatitis: Recurrent			7- Post Transplant	Hepatic Artery Thrombosis
7- Post Transplant	Recurrent Disease (non-Hepatitis)			7- Post Transplant	Other Vascular Thrombosis
7- Post Transplant	Acute Rejection			7- Post Transplant	Hepatic outflow obstruction
7- Post Transplant	Infection			7- Post Transplant	Portal vein thrombosis
7- Post Transplant	Other, Specify			7- Post Transplant	Diffuse Cholangiopathy
7- Post Transplant	Did patient have any acute rejection episodes between transplant and discharge			7- Post Transplant	Hepatitis: DeNovo
9- Immunosupression Other	Are any medications given currently for maintenance or anti-rejection			7- Post Transplant	Hepatitis: Recurrent
9- Immunosupression Other	immunosuppression medication			7- Post Transplant	Recurrent Disease (non-Hepatitis)
9- Immunosupression Other	immunosuppression medication indication			7- Post Transplant	Acute Rejection
9- Immunosupression Other	days of induction			7- Post Transplant	Infection
				7- Post Transplant	Other, Specify
	Public Burden Statement			7- Post Transplant	Did patient have any acute rejection episodes between transplant and discharge
				9- Immunosupression Other	Are any medications given currently for maintenance or anti-rejection
				9- Immunosupression Other	immunosuppression medication
				9- Immunosupression Other	immunosuppression medication indication
				9- Immunosupression Other	days of induction
					Public Burden Statement