19 Heart_Lung Transplant Recipient Registration_Form.xlsx

TRR - Heart/Lung - 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-DonorInformation	UNOS Donor ID #	Display Only - Cascades from TCR		3-DonorInformation	UNOS Donor ID #	Display Only - Cascades from TCR
3-DonorInformation	Donor Type	Display Only - Cascades from feedback		3-DonorInformation	Donor Type	Display Only - Cascades from feedback
3-DonorInformation	OPO	Display Only - Cascades from feedback		3-DonorInformation	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	Other Mechanism			4-Patient Status	Prostaglandins
4-Patient Status	Other Mechanism, Specify			4-Patient Status	Intravenous Inotropes
4-Patient Status	Prostacyclin Infusion			4-Patient Status	Ventilator
4-Patient Status	Prostacyclin Inhalation			4-Patient Status	Inhaled NO
4-Patient Status	Patient on Ventricular Assist Device			4-Patient Status	Other Mechanism
4-Patient Status	Life Support: VAD Brand1			4-Patient Status	Other Mechanism, Specify
4-Patient Status	Life Support: VAD Brand1//Specify			4-Patient Status	Prostacyclin Infusion
4-Patient Status	Life Support: VAD Brand2			4-Patient Status	Prostacyclin Inhalation
4-Patient Status	Life Support: VAD Brand2//Specify			4-Patient Status	Patient on Ventricular Assist Device
4-Patient Status	Functional Status			4-Patient Status	Life Support: VAD Brand1
4-Patient Status	Working for income			4-Patient Status	Life Support: VAD Brand1//Specify
4-Patient Status	Primary Source of Payment			4-Patient Status	Life Support: VAD Brand2
4-Patient Status	Primary Source of Payment, Specify			4-Patient Status	Life Support: VAD Brand2//Specify
5- Pretransplant	Height			4-Patient Status	Functional Status
5- Pretransplant	Height in Centimeters//Status	Value or status is reported, not both		4-Patient Status	Academic Progress
5- Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only		4-Patient Status	Academic Activity Level
5- Pretransplant	Weight			4-Patient Status	Primary Source of Payment
5- Pretransplant	Weight in Kilograms//Status	Value or status is reported, not both		4-Patient Status	Primary Source of Payment, Specify
5- Pretransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only		4-Patient Status	Cognitive Development
5- Pretransplant	BMI	Display Only - Cascades from Database		4-Patient Status	Motor Development
5- Pretransplant	BMI://%ile	Calculated for display only		5- Pretransplant	Date of Measurement
5- Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database		5- Pretransplant	Height
5- Pretransplant	Previous Transplant Date	Display Only - Cascades from Database		5- Pretransplant	Height in Centimeters//Status	Value or status is reported, not both
5- Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database		5- Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only
5- PreTransplant	HIV Serostatus			5- Pretransplant	Weight
5- PreTransplant	NAT HIV			5- Pretransplant	Weight in Kilograms//Status	Value or status is reported, not both
5- PreTransplant	CMV Status			5- Pretransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only
6- PreTransplant	HBV Core Antibody			5- Pretransplant	BMI	Display Only - Cascades from Database
5- PreTransplant	HBV Surface Antibody Total			5- Pretransplant	BMI://%ile	Calculated for display only
5- PreTransplant	HBV Surface Antigen			5- Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database
5- PreTransplant	NAT HBV			5- Pretransplant	Previous Transplant Date	Display Only - Cascades from Database
5- PreTransplant	HCV Serostatus			5- Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database
5- PreTransplant	NAT HCV			5- PreTransplant	HIV Serostatus
5- PreTransplant	EBV Serostatus			5- PreTransplant	NAT HIV
5-Pretransplant	PA (sys)mm/Hg			5- PreTransplant	CMV Status
5-Pretransplant	PA (sys)mm/Hg//Status	Value or status is reported, not both		6- PreTransplant	HBV Core Antibody
5-Pretransplant	PA(sys)mm/Hg Inotropes/VASODilators			5- PreTransplant	HBV Surface Antibody Total
5-Pretransplant	PA(dia) mm/Hg			5- PreTransplant	HBV Surface Antigen
5-Pretransplant	PA(dia) mm/HG//Status	Value or status is reported, not both		5- PreTransplant	NAT HBV
5-Pretransplant	PA (dia) mm/Hg Inotropes/Vasodilators			5- PreTransplant	HCV Serostatus
5-Pretransplant	PA(mean) mm/Hg			5- PreTransplant	NAT HCV
5-Pretransplant	PA(mean) mm/Hg//Status	Value or status is reported, not both		5- PreTransplant	EBV Serostatus
5-Pretransplant	PA (mean) mm/Hg Inotropes/Vasodilators			5-Pretransplant	PA (sys)mm/Hg
5-Pretransplant	PCW(mean) mm/Hg			5-Pretransplant	PA (sys)mm/Hg//Status	Value or status is reported, not both
5-Pretransplant	PCW(mean) mm/Hg//Status	Value or status is reported, not both		5-Pretransplant	PA(sys)mm/Hg Inotropes/VASODilators
5-Pretransplant	PCW (mean) mm/Hg Inotropes/Vasodilators			5-Pretransplant	PA(dia) mm/Hg
5-Pretransplant	CO L/min			5-Pretransplant	PA(dia) mm/HG//Status	Value or status is reported, not both
5-Pretransplant	CO L/min//Status	Value or status is reported, not both		5-Pretransplant	PA (dia) mm/Hg Inotropes/Vasodilators
5-Pretransplant	CO L/min Inotropes/Vasodilators CO L/min Inotropes/Vasodilators			5-Pretransplant	PA(mean) mm/Hg
5-Pretransplant	Most Recent Serum Creatinine			5-Pretransplant	PA(mean) mm/Hg//Status	Value or status is reported, not both
5-Pretransplant	Most Recent Serum Creatinine//Status	Value or status is reported, not both		5-Pretransplant	PA (mean) mm/Hg Inotropes/Vasodilators
5-Pretransplant	Most Recent Total Bilirubin			5-Pretransplant	PCW(mean) mm/Hg
5-Pretransplant	Most Recent Total Bilirubin//Status	Value or status is reported, not both		5-Pretransplant	PCW(mean) mm/Hg//Status	Value or status is reported, not both
5-Pretransplant	Chronic Steroid Use			5-Pretransplant	PCW (mean) mm/Hg Inotropes/Vasodilators
5-Pretransplant	FVC			5-Pretransplant	CO L/min
5-Pretransplant	FVC % predicted//Status	Value or status is reported, not both		5-Pretransplant	CO L/min//Status	Value or status is reported, not both
5-Pretransplant	FeV1			5-Pretransplant	CO L/min Inotropes/Vasodilators CO L/min Inotropes/Vasodilators
5-Pretransplant	FeV1 % predicted//Status	Value or status is reported, not both		5- Pretransplant	Cardiac Index	Display Only - Cascades from Database
5-Pretransplant	pCO2			5-Pretransplant	Most Recent Serum Creatinine
5-Pretransplant	pCO2 mm/Hg//Status	Value or status is reported, not both		5-Pretransplant	Most Recent Serum Creatinine//Status	Value or status is reported, not both
5-Pretransplant	Transfusions			5-Pretransplant	Most Recent Total Bilirubin
5-Pretransplant	Infection Requiring IV Therapy within 2 wks prior to Tx			5-Pretransplant	Most Recent Total Bilirubin//Status	Value or status is reported, not both
5-Pretransplant	Dialysis			5-Pretransplant	Chronic Steroid Use
5-Pretransplant	Prior Cardiac Surgery (non-transplant)			5-Pretransplant	FVC
5-Pretransplant	If yes, check all that apply			5-Pretransplant	FVC % predicted//Status	Value or status is reported, not both
5-Pretransplant	Prior Cardiac Surgery//Specify			5-Pretransplant	FeV1
5-Pretransplant	Prior Lung Surgery (non-transplant)			5-Pretransplant	FeV1 % predicted//Status	Value or status is reported, not both
5-Pretransplant	If yes, check all that apply			5-Pretransplant	pCO2
5-Pretransplant	Prior Lung Surgery//Specify			5-Pretransplant	pCO2 mm/Hg//Status	Value or status is reported, not both
5-Pretransplant	Episode of Ventilatory Support			5-Pretransplant	Transfusions
5-Pretransplant	If yes, indicate most recent timeframe			5-Pretransplant	Infection Requiring IV Therapy within 2 wks prior to Tx
5-Pretransplant	Tracheostomy			5-Pretransplant	Dialysis
6-Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback		5-Pretransplant	Episode of Ventilatory Support
6-Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback		5-Pretransplant	If yes, indicate most recent timeframe
6-Transplant Procedure	Procedure Type	Display Only - Cascades from feedback		5-Pretransplant	Tracheostomy
6-Transplant Procedure	Heart Procedure			5-Pretransplant	Prior Thoracic Surgery other than prior transplant
6-Transplant Procedure	Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time): Heart, Heart-Lung			5-Pretransplant	If yes, number of prior sternotomies
6-Transplant Procedure	Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time)://Status	Value or status is reported, not both		5-Pretransplant	If yes, number of prior thoracotomies
6-Transplant Procedure	Lung(s) perfused prior to transplant?			5-Pretransplant	Prior congenital cardiac surgery
6-Transplant Procedure	Perfusion occurred at:			5-Pretransplant	If yes, palliative surgery
6-Transplant Procedure	Perfusion performed by:			5-Pretransplant	If yes, corrective surgery
6-Transplant Procedure	Total time on perfusion			5-Pretransplant	If yes, single ventricular physiology
6-Transplant Procedure	Lung(s) received at transplant center			5-Pretransplant	Most Recent Anti-A Titer
6-Transplant Procedure	On ice			5-Pretransplant	Most Recent Anti-A Titer//Sample Date
6-Transplant Procedure	On pump			5-Pretransplant	Most Recent Anti-B Titer
6-Transplant Procedure	Right Lung/Enbloc: Stayed on pump Put on ice Left Lung: Stayed on pump Put on ice			5-Pretransplant	Most Recent Anti-B Titer//Sample Date
7-Post Transplant	Graft Status			6-Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback
7-Post Transplant	Date of Graft Failure			6-Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback
7-Post Transplant	Primary Cause of Graft Failure			6-Transplant Procedure	Procedure Type	Display Only - Cascades from feedback
7-Post Transplant	Primary Cause of Graft Failure// Other Specify			6-Transplant Procedure	Heart Procedure
7 - PostTransplant	Stroke			6-Transplant Procedure	Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time): Heart, Heart-Lung
7 - PostTransplant	Dialysis			6-Transplant Procedure	Total organ preservation time from cross clamp to in-situ reperfusion (include warm and cold time)://Status	Value or status is reported, not both
7- Post Transplant	Ventilator Support			6-Transplant Procedure	Lung(s) perfused prior to transplant?
7- Post Transplant	Reintubated			6-Transplant Procedure	Perfusion occurred at:
7 - PostTransplant	Permanent Pacemaker			6-Transplant Procedure	Perfusion performed by:
7 - PostTransplant	Airway Dehiscence			6-Transplant Procedure	Total time on perfusion
7- Post Transplant	Did patient have any acute rejection episodes between transplant and discharge			6-Transplant Procedure	Lung(s) received at transplant center
7- Post Transplant	Intubated at 72 hours			6-Transplant Procedure	On ice
7- Post Transplant	PaO2 at 72 hours			6-Transplant Procedure	On pump
7- Post Transplant	PaO2 at 72 hours//Status	Value or status is reported, not both		6-Transplant Procedure	Right Lung/Enbloc: Stayed on pump Put on ice Left Lung: Stayed on pump Put on ice
7- Post Transplant	FiO2 at 72 hours			7- Post Transplant	Graft Status
7- Post Transplant	FiO2 at 72 hours//Status	Value or status is reported, not both		7- Post Transplant	Date of Graft Failure
7- Post Transplant	ECMO a 72 hours			7- Post Transplant	Primary Cause of Graft Failure
7- Post Transplant	Inhaled NO at 72 hours			7- Post Transplant	Primary Cause of Graft Failure// Other Specify
9- Immunosupression Other	Are any medications given currently for maintenance or anti-rejection			7- Post Transplant	Ventilator Support
9- Immunosupression Other	immunosuppression medication			7- Post Transplant	Reintubated
9- Immunosupression Other	immunosuppression medication indication			7 - Post Transplant	Permanent Pacemaker
9- Immunosupression Other	days of induction			7 - Post Transplant	Airway Dehiscence
				7- Post Transplant	Did patient have any acute rejection episodes between transplant and discharge
	Public Burden Statement			7- Post Transplant	Intubated at 72 hours
				7- Post Transplant	PaO2 at 72 hours
				7- Post Transplant	PaO2 at 72 hours//Status	Value or status is reported, not both
				7- Post Transplant	FiO2 at 72 hours
				7- Post Transplant	FiO2 at 72 hours//Status	Value or status is reported, not both
				7- Post Transplant	ECMO a 72 hours
				7- Post Transplant	Inhaled NO at 72 hours
				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
				8 - PostTransplant	Stroke
				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