HeartLung Transplant Recipient Follow Up 6 Month_Instructions

Thoracic 6 Month Transplant Recipient Follow-up (TRF) Field Descriptions

Transplant Recipient Follow-up (TRF) records are generated in Tiedi^®at six months, one year and annually thereafter following transplantation, until either graft failure, recipient death or lost to follow-up is reported. Forms are generated by the age at transplant, not the age at listing. Pediatric follow-up records will continue to generate through the recipient's 25th birthday. The system will automatically update the next follow-up record to Adult as of the recipient's 26th birthday.

The TRF record is to be completed by the transplant center responsible for follow-up of the recipient 6 months.

Note: The record is to contain only the applicable patient information between the completion of the TRR and the 6 month follow-up. It is not to contain information pertaining solely to the next follow-up period. For example: the 6-month follow-up should contain information from the time after the TRR was completed to the 6-month transplant anniversary date; the 1-year follow-up should contain information from the day after the 6-month transplant anniversary date to the 1-year transplant anniversary date.

If the recipient dies or experiences a graft failure between follow-up intervals, complete an interim record containing the information pertinent to the patient no later than the date of death or graft failure. For example: an interim graft failure is reported with a graft failure date of March 10. The patient status date should also be March 10 and the information collected on the form should be based on patient evaluation no later than March 10. 

TRF records generated before June 30, 2002 are forgiven except for the one-year, three-year, death/graft failure or most recently expected follow-up record. Amnesty records may be accessed by selecting the Expected/Amnesty and/or Amnesty option on the Search page. (For additional information, see Searching for Patient Records and Records Generation.)

If the patient is lost to follow-up, follow the steps for Reporting Lost to Follow-up.

The TRF record must be completed within 90 days from the record generation date. See OPTN/UNOS Policies for additional information. Use the search feature to locate specific policy information on Data Submission Requirements.

To correct information that is already displayed on an electronic record, call the UNet^SM Help Desk at 1-800-978-4334.

Recipient Information

Name: Verify the last name, first name and middle initial of the transplant recipient is correct. If the information is incorrect, corrections may be made on the recipient's TCR record.

DOB: Verify the displayed date is the recipient's date of birth. If the information is incorrect, corrections may be made on the recipient's TCR record.

SSN: Verify the recipient's social security number is correct. If the information is incorrect, contact the Help Desk at 1-800-978-4334.

Gender: Verify recipient’s sex (Male or Female), based on biologic and physiologic traits, at birth. If sex at birth is unknown, report sex at time of registration as reported by recipient or documented in medical record. The intent of this data collection field is to capture physiologic characteristics that may have an impact on recipient size matching or graft outcome. If the information is incorrect, corrections may be made on the recipient's TCR record.

HIC: Verify the 9 to 11 character Health Insurance Claim number for the recipient indicated on the recipient's most recently updated TCR record is correct. If the recipient does not have a HIC number, you may leave this field blank.

Tx Date: The recipient's transplant date, reported in the Recipient Feedback, will display. Verify that the displayed transplant date is correct. The transplant date is determined by the start of the organ anastomosis during transplant or the start of the islet infusion. Organ transplants include solid organ transplants and islet infusions. An organ transplant procedure is complete when any of the following occurs:

The chest or abdominal cavity is closed and the final skin stitch or staple is applied.

The transplant recipient leaves the operating room, even if the chest or abdominal cavity cannot be closed.

The islet infusion is complete.

Previous Follow-up: Transplant Recipient Registration displays.

Previous Px Stat Date: The recipient's patient status date, reported in the previous TRF record, will display. Verify the recipient's previous patient status date is correct.

Transplant Discharge Date: Verify that the discharge date displayed is the date the recipient was released to go home, or enter the date the recipient was released. The patient's hospital stay includes total time spent in different units of the hospital, including medical and rehab.

Note: The Transplant Discharge Date can only be edited on the patient's TRR. The corrected information will automatically update on the 6 month TRF record.

State of Permanent Residence: Select the name of the state of the recipient's permanent address at the time of follow-up (location of full-time residence, not follow-up center location). This field is required. (List of State codes)

Zip Code: Enter the recipient's permanent zip code at the time of follow-up (location of full-time residence, not follow-up center location). This field is required.

Provider Information (At Time of Follow-up)

Date: Last Seen, Retransplanted or Death: Enter the date the patient was last seen, or the date of death, or retransplant for this recipient, using the standard 8-digit numeric format of MM/DD/YYYY.  If the recipient died or the graft failed, and you have not completed an interim follow-up indicating these events, the 6-month follow-up should be completed indicating one of those two events. This field is required.

Patient Status: If the recipient is living at the time of follow-up, select Living. If the recipient died during this follow-up period, select Dead. Follow-up forms will no longer be generated for this patient. If Dead is selected, indicate the cause of death. If the recipient received another thoracic organ from a different donor during the follow-up period, select Retransplanted. If the recipient was not seen during this follow-up period, select Not Seen; however, an annual follow-up form will be generated for this patient next year. This field is required.

Living
Dead
Retransplanted
Not Seen

Primary Cause of Death: If the Patient Status is Dead, select the patient's cause of death. If an Other code is selected, enter the other cause of death in the space provided. (List of Primary Cause of Death codes)

Contributory Cause of Death: If the Patient Status is Dead, select the patient's contributory cause of death. If an Other code is selected, enter the other cause of death in the space provided. (List of Contributory Cause of Death codes)

Clinical Information

Graft Status: If the graft is functioning at the time of follow-up, select Functioning. If the graft is not functioning, select Failed. This field is required.

Note: If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.

If Failed is selected, complete the following fields.

Date of Graft Failure: Enter the date of graft failure using the standard 8-digit numeric format of MM/DD/YYYY.

Primary Cause of Graft Failure: Select the cause of graft failure. (List of Graft Failure codes)

Primary Non-Function
Acute Rejection
Chronic Rejection/Atherosclerosis
Other, Specify

Date Test Performed -

FEV1 -

FVC

FEF 25-75

Date Test Performed

FEV1 -

FVC

FEF 25-75

Date Test Performed

FEV1 -

FVC

FEF 25-75

Current Supplemental O2 requirements at rest and/or at exercise

At rest: FiO2 or Flow -

With exercise: FiO2 or Flow –

Viral Detection: The following fields will be required on 6-month and 1-year TRFs if the recipient received an organ from a donor that was classified as “CDC High Risk” on the DDR.

HIV Serology: Select the results from the drop-down list.

Positive
Negative
UKN/Cannot Disclose
Not Done

HIV NAT: PCR or NAT testing can be used to submit response. Select the results from the drop-down list.

Positive
Negative
UKN/Cannot Disclose
Not Done

HbsAg: Select the results from the drop-down list.

Positive
Negative
UKN/Cannot Disclose
Not Done

HBV DNA: PCR or NAT testing can be used to submit response. Select the results from the drop-down list.

Positive
Negative
UKN/Cannot Disclose
Not Done

HBV Core Antibody: Select the results from the drop-down list.

Positive
Negative
UKN/Cannot Disclose
Not Done

HCV Serology: Select the results from the drop-down list.

Positive
Negative
UKN/Cannot Disclose
Not Done

   HCV NAT (Nucleic Acid Testing): Select the results from the drop-down list.

Positive
Negative
UKN/Cannot Disclose
Not Done

Titer Information: For heart only recipients, complete if the recipient received an incompatible blood type donor heart and death or graft failure is reported within 6 months of transplant:

Most Recent Anti-B Titer: Select the Most Recent Anti-B Titer value, Not taken or Not available if applicable. Enter the Sample Date in mm/dd/yyyy format. The date to be reported is the date when the candidate's blood was drawn.

Note: The Sample Date cannot be prior to the recipient's transplant date, cannot be after the graft failure or the death date and cannot be a future date.  

Note: This field will only display if the recipient’s ABO blood-type is A or O.

Most Recent Anti-A Titer: Select the Most Recent Anti-A Titer value, Not taken or Not available if applicable. Enter the Sample Date in mm/dd/yyyy format. The date to be reported is the date when the candidate's blood was drawn.   

Note: The Sample Date cannot be prior to the recipient's transplant date, cannot be after the graft failure or the death date and cannot be a future date.  

Note: This field will only display if the recipient’s ABO blood-type is B or O.