7 Heart Transplant Recipient Registration_Form.xlsx

TRR - 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	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	Physician Name			2-Provider Information	Physician Name
2-Provider Information	Physician NPI#			2-Provider Information	Physician NPI#
2-Provider Information	Surgeon Name			2-Provider Information	Surgeon Name
2-Provider Information	Surgeon NPI#			2-Provider Information	Surgeon NPI#
3- Donor Information	UNOS Donor ID #	Display Only - Cascades from TCR		3- Donor Information	UNOS Donor ID #	Display Only - Cascades from TCR
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	Medical Condition at time of transplant			4-Patient Status	Medical Condition at time of transplant
4-Patient Status	Patient on Life Support			4-Patient Status	Patient on Life Support
4-Patient Status	Extra Corporeal Membrane Oxygenation			4-Patient Status	Extra Corporeal Membrane Oxygenation
4-Patient Status	Intra Aortic Balloon Pump			4-Patient Status	Intra Aortic Balloon Pump
4-Patient Status	Prostaglandins			4-Patient Status	Prostaglandins
4- Patient Statu	Intravenous Inotropes			4- Patient Statu	Intravenous Inotropes
4- Patient Statu	Inhaled NO			4- Patient Statu	Ventilator
4- Patient Statu	Ventilator			4- Patient Statu	Inhaled NO
4- Patient Statu	Other Mechanism			4- Patient Statu	Other Mechanism
4- Patient Statu	Other Mechanism, Specify			4- Patient Statu	Other Mechanism, Specify
4 -Patient Status	Patient on Ventricular Assist Device			4 -Patient Status	Patient on Ventricular Assist Device
4 -Patient Status	Life Support: VAD Brand1			4 -Patient Status	Life Support: VAD Brand1
4 -Patient Status	Life Support: VAD Brand1//Specify			4 -Patient Status	Life Support: VAD Brand1//Specify
4 -Patient Status	Life Support: VAD Brand2			4 -Patient Status	Life Support: VAD Brand2
4 -Patient Status	Life Support: VAD Brand2//Specify			4 -Patient Status	Life Support: VAD Brand2//Specify
4 -Patient Status	Functional Status			4 -Patient Status	Functional Status
4 -Patient Status	Working for income			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 Surface Antigen			5- Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database
5- PreTransplant	NAT HBV			5- PreTransplant	HIV Serostatus
5- PreTransplant	HCV Serostatus			5- PreTransplant	NAT HIV
5- PreTransplant	NAT HCV			5- PreTransplant	CMV Status
5- PreTransplant	EBV Serostatus			6- PreTransplant	HBV Core Antibody
5-Pretransplant	PA (sys)mm/Hg			5- PreTransplant	HBV Surface Antibody Total
5-Pretransplant	PA (sys)mm/Hg//Status	Value or status is reported, not both		5- PreTransplant	HBV Surface Antigen
5-Pretransplant	PA(sys)mm/Hg Inotropes/VASODilators			5- PreTransplant	NAT HBV
5-Pretransplant	PA(dia) mm/Hg			5- PreTransplant	HCV Serostatus
5-Pretransplant	PA(dia) mm/HG//Status	Value or status is reported, not both		5- PreTransplant	NAT HCV
5-Pretransplant	PA (dia) mm/Hg Inotropes/Vasodilators			5- PreTransplant	EBV Serostatus
5-Pretransplant	PA(mean) mm/Hg			5-Pretransplant	PA (sys)mm/Hg
5-Pretransplant	PA(mean) mm/Hg//Status	Value or status is reported, not both		5-Pretransplant	PA (sys)mm/Hg//Status	Value or status is reported, not both
5-Pretransplant	PA (mean) mm/Hg Inotropes/Vasodilators			5-Pretransplant	PA(sys)mm/Hg Inotropes/VASODilators
5-Pretransplant	PCW(mean) mm/Hg			5-Pretransplant	PA(dia) mm/Hg
5-Pretransplant	PCW(mean) mm/Hg//Status	Value or status is reported, not both		5-Pretransplant	PA(dia) mm/HG//Status	Value or status is reported, not both
5-Pretransplant	PCW (mean) mm/Hg Inotropes/Vasodilators			5-Pretransplant	PA (dia) mm/Hg Inotropes/Vasodilators
5-Pretransplant	CO L/min			5-Pretransplant	PA(mean) mm/Hg
5-Pretransplant	CO L/min//Status	Value or status is reported, not both		5-Pretransplant	PA(mean) mm/Hg//Status	Value or status is reported, not both
5-Pretransplant	CO L/min Inotropes/Vasodilators CO L/min Inotropes/Vasodilators			5-Pretransplant	PA (mean) mm/Hg Inotropes/Vasodilators
5-Pretransplant	Most Recent Serum Creatinine			5-Pretransplant	PCW(mean) mm/Hg
5-Pretransplant	Most Recent Serum Creatinine//Status	Value or status is reported, not both		5-Pretransplant	PCW(mean) mm/Hg//Status	Value or status is reported, not both
5-Pretransplant	Most Recent Total Bilirubin			5-Pretransplant	PCW (mean) mm/Hg Inotropes/Vasodilators
5-Pretransplant	Most Recent Total Bilirubin//Status	Value or status is reported, not both		5-Pretransplant	CO L/min
5-Pretransplant	Chronic Steroid Use			5-Pretransplant	CO L/min//Status	Value or status is reported, not both
5-Pretransplant	Transfusions			5-Pretransplant	CO L/min Inotropes/Vasodilators CO L/min Inotropes/Vasodilators
5-Pretransplant	Infection Requiring IV Therapy within 2 wks prior to Tx			5- Pretransplant	Cardiac Index	Display Only - Cascades from Database
5-Pretransplant	Dialysis			5-Pretransplant	Most Recent Serum Creatinine
5-Pretransplant	Prior Cardiac Surgery (non-transplant)			5-Pretransplant	Most Recent Serum Creatinine//Status	Value or status is reported, not both
5-Pretransplant	If yes, check all that apply			5-Pretransplant	Most Recent Total Bilirubin
5-Pretransplant	Prior Cardiac Surgery//Specify			5-Pretransplant	Most Recent Total Bilirubin//Status	Value or status is reported, not both
5-Pretransplant	Prior Lung Surgery (non-transplant)			5-Pretransplant	Chronic Steroid Use
5-Pretransplant	If yes, check all that apply			5-Pretransplant	Transfusions
5-Pretransplant	Prior Lung Surgery//Specify			5-Pretransplant	Infection Requiring IV Therapy within 2 wks prior to Tx
5-Pretransplant	Episode of Ventilatory Support			5-Pretransplant	Dialysis
5-Pretransplant	If yes, indicate most recent timeframe			5-Pretransplant	Episode of Ventilatory Support
5- Pretransplant	Cardiac Index	Display Only - Cascades from Database		5-Pretransplant	If yes, indicate most recent timeframe
6-Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback		5-Pretransplant	Prior Thoracic Surgery other than prior transplant
6-Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback		5-Pretransplant	If yes, number of prior sternotomies
6-Transplant Procedure	Procedure Type	Display Only - Cascades from feedback		5-Pretransplant	If yes, number of prior thoracotomies
6-Transplant Procedure	Heart Procedure			5-Pretransplant	Prior congenital cardiac surgery
6-Transplant Procedure	Total ischemia Time: Heart, Heart-Lung			5-Pretransplant	If yes, palliative surgery
6-Transplant Procedure	Total ischemia Time: Heart, Heart-Lung//Status	Value or status is reported, not both		5-Pretransplant	If yes, corrective surgery
7- Post Transplant	Heart Graft Status			5-Pretransplant	If yes, single ventricular physiology
7- Post Transplant	Heart Date of Graft Failure			5- PreTransplant	If yes, specify type
7- Post Transplant	Heart Primary Cause of Graft Failure			5-Pretransplant	Most Recent Anti-A Titer
7- Post Transplant	Heart Primary Cause of Graft Failure//Other Specify			5-Pretransplant	Most Recent Anti-A Titer//Sample Date
8 - PostTransplant	Stroke			5-Pretransplant	Most Recent Anti-B Titer
7 - PostTransplant	Dialysis			5-Pretransplant	Most Recent Anti-B Titer//Sample Date
7 - PostTransplant	Permanent Pacemaker			6-Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback
7 - PostTransplant	Airway Dehiscence			6-Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback
7- Post Transplant	Did patient have any acute rejection episodes between transplant and discharge			6-Transplant Procedure	Procedure Type	Display Only - Cascades from feedback
7- Post Transplant	Primary Cause of Graft Failure//Specify			6-Transplant Procedure	Heart Procedure
9- Immunosupression Other	Are any medications given currently for maintenance or anti-rejection			6-Transplant Procedure	Total ischemia Time: Heart, Heart-Lung
9- Immunosupression Other	immunosuppression medication			6-Transplant Procedure	Total ischemia Time: Heart, Heart-Lung//Status	Value or status is reported, not both
9- Immunosupression Other	immunosuppression medication indication			7- Post Transplant	Heart Graft Status
9- Immunosupression Other	days of induction			7- Post Transplant	Heart Date of Graft Failure
				7- Post Transplant	Heart Primary Cause of Graft Failure
	Public Burden Statement			7- Post Transplant	Heart Primary Cause of Graft Failure//Other Specify
				7 - PostTransplant	Stroke
				7- Post Transplant	Reintubated
				7 - PostTransplant	Permanent Pacemaker
				7 - PostTransplant	Airway Dehiscence
				7- Post Transplant	Did patient have any acute rejection episodes between transplant and discharge
				7- Post Transplant	Most Recent Anti-A Titer
				7- Post Transplant	Most Recent Anti-A Titer//Sample Date
				7- Post Transplant	Most Recent Anti-B Titer
				7- Post Transplant	Most Recent Anti-B Titer//Sample Date
				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