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UNOS_Employees
PATIENT REGISTRATION
PRE-TX
TRANSPLANT
DONOR
DISCHARGE
DONOR INFORMATION
Last Name:
First Name:
Gender:
Male
Female
Male
Age:
49
Age Unit:
Months
Years
ABO Blood Group:
O
Height:
cm
ST=
Missing
Unknown
N/A
Not Done
Weight:
kg
ST=
Missing
Unknown
N/A
Not Done
Mechanism of Death:
DROWNING
SEIZURE
ASPHYXIATION
ELECTRICAL
STAB
SIDS
DEATH FROM NATURAL CAUSES
DRUG INTOXICATION
CARDIOVASCULAR
GUNSHOT WOUND
BLUNT INJURY
INTRACRANIAL HEMORRHAGE/STROKE
NONE OF THE ABOVE
Cause of Death:
ANOXIA
CEREBROVASCULAR/STROKE
HEAD TRAUMA
CNS TUMOR
OTHER SPECIFY
Specify:
Circumstances of Death:
MVA
SUICIDE
HOMICIDE
CHILD-ABUSE
Accident, Non-MVA
DEATH FROM NATURAL CAUSES
NONE OF THE ABOVE
Serum Creatinine:
mg/dl
ST=
Missing
Unknown
N/A
Not Done
BUN:
mg/dl
ST=
Missing
Unknown
N/A
Not Done
Total Bilirubin:
mg/dl
ST=
Missing
Unknown
N/A
Not Done
SGOT/AST:
u/L
ST=
Missing
Unknown
N/A
Not Done
SGPT/ALT:
u/L
ST=
Missing
Unknown
N/A
Not Done
Protein in Urine:
YES
NO
UNK
Last Serum Sodium Prior to Procurement:
mEq/L
ST=
Missing
Unknown
N/A
Not Done
INR:
ST=
Missing
Unknown
N/A
Not Done
Blood pH:
ST=
Missing
Unknown
N/A
Not Done
Hematocrit:
%
ST=
Missing
Unknown
N/A
Not Done
Anti-CMV:
Positive
Negative
Unknown
Cannot Disclose
Not Done
Indeterminate
Pending
HBsAg:
Positive
Negative
Unknown
Cannot Disclose
Not Done
Indeterminate
Pending
Anti-HBC:
Positive
Negative
Unknown
Cannot Disclose
Not Done
Indeterminate
Pending
Anti-HCV:
Positive
Negative
Unknown
Cannot Disclose
Not Done
Indeterminate
Pending
Anti-HIV I/II:
Positive
Negative
Unknown
Cannot Disclose
Not Done
Indeterminate
Pending
Anti-HTLV I/II:
Positive
Negative
Unknown
Cannot Disclose
Not Done
Indeterminate
Pending
RPR-VDRL:
Positive
Negative
Unknown
Cannot Disclose
Not Done
Indeterminate
Pending
HBsAb:
Positive
Negative
Unknown
Cannot Disclose
Not Done
Indeterminate
Pending
EBV (VCA) (lgG):
Positive
Negative
Unknown
Cannot Disclose
Not Done
Indeterminate
Pending
EBV (VCA) (lgM):
Positive
Negative
Unknown
Cannot Disclose
Not Done
Indeterminate
Pending
EBNA:
Positive
Negative
Unknown
Cannot Disclose
Not Done
Indeterminate
Pending
Donor management: (Any medications administered within 24 hours prior to crossclamp.)
Steroids:
YES
NO
UNK
Diuretics:
YES
NO
UNK
T3:
YES
NO
UNK
T4:
YES
NO
UNK
Anticonvulsants:
YES
NO
UNK
Antihypertensives:
YES
NO
UNK
Vasodilators:
YES
NO
UNK
DDAVP:
YES
NO
UNK
Heparin:
YES
NO
UNK
Arginine Vasopressin:
YES
NO
UNK
Insulin:
YES
NO
UNK
Other/Specify:
Inotropic Medications at Time of Cross Clamp:
YES
NO
UNK
Medication:
Dopamine
Dobutamine
Epinephrine
Levophed
Neosynephrine
Isoproterenol (Isuprel)
Other, specify
Medication:
Dopamine
Dobutamine
Epinephrine
Levophed
Neosynephrine
Isoproterenol (Isuprel)
Other, specify
Medication:
Dopamine
Dobutamine
Epinephrine
Levophed
Neosynephrine
Isoproterenol (Isuprel)
Other, specify
Specify:
Specify:
Specify:
Number of transfusions during this (terminal) hospitalization:
NONE
1 - 5
6 - 10
GREATER THAN 10
UNKNOWN
Three or more inotropic agents at time of incision:
YES
NO
Clinical Infection:
YES
NO
UNK
Culture:
Blood:
YES
NO
Lung:
YES
NO
Urine:
YES
NO
Other:
YES
NO
Other, specify:
Cigarette Use (> 20 pack years) - Ever:
YES
NO
UNK
AND continued in last six months:
YES
NO
UNK
Cocaine Use - Ever:
YES
NO
UNK
AND continued in last six months:
YES
NO
UNK
Other Drug Use (non - IV) - Ever:
YES
NO
UNK
AND continued in last six months:
YES
NO
UNK
Heavy Alcohol Use (heavy= 2+ drinks/day):
YES
NO
UNK
Tattoos:
YES
NO
UNK
Does the Donor meet "High Risk" guidelines for organ donation:
YES
NO
UNK
History of Diabetes:
NO
YES, 0-5 YEARS
YES, 6-10 YEARS
YES, >10 YEARS
YES, DURATION UNKNOWN
UNKNOWN
Insulin Dependent:
NO
YES, 0-5 YEARS
YES, 6-10 YEARS
YES, >10 YEARS
YES, DURATION UNKNOWN
UNKNOWN
History of Hypertension:
NO
YES, 0-5 YEARS
YES, 6-10 YEARS
YES, >10 YEARS
YES, UNKNOWN DURATION
UNKNOWN
Diet:
YES
NO
UNK
Diuretics:
YES
NO
UNK
Other Hypertensive Medication:
YES
NO
UNK
History of Cancer:
NO
SKIN - SQUAMOUS, BASAL CELL
SKIN - MELANOMA
CNS TUMOR - ASTROCYTOMA
CNS TUMOR - GLIOBLASTOMA MULTIFORME
CNS TUMOR - MEDULLOBLASTOMA
CNS TUMOR - NEUROBLASTOMA
CNS TUMOR - ANGIOBLASTOMA
CNS TUMOR - MENINGIOMA
CNS TUMOR - OTHER
GENITOURINARY - BLADDER
GENITOURINARY - UTERINE CERVIX
GENITOURINARY - UTERINE BODY ENDOMETRIAL
GENITOURINARY - UTERINE BODY CHORIOCARCINOMA
GENITOURINARY - VULVA
GENITOURINARY - OVARIAN
GENITOURINARY - PENIS, TESTICULAR
GENITOURINARY - PROSTATE
GENITOURINARY - KIDNEY
GENITOURINARY - UNKNOWN
GASTROINTESTINAL - ESOPHAGEAL
GASTROINTESTINAL - STOMACH
GASTROINTESTINAL - SMALL INTESTINE
GASTROINTESTINAL - COLO-RECTAL
GASTROINTESTINAL - LIVER & BILIARY TRACT
GASTROINTESTINAL - PANCREAS
BREAST
THYROID
TONGUE/THROAT
LARYNX
LUNG (include bronchial)
LEUKEMIA/LYMPHOMA
UNKNOWN
OTHER, SPECIFY
Specify:
Cancer Free Interval:
years
ST=
Missing
Unknown
N/A
Not Done
Intracranial:
YES
NO
UNK
Extracranial:
YES
NO
UNK
Skin:
YES
NO
UNK
Was this a non - heartbeating donor?
No: Brain-dead
Yes: Controlled
Yes: Uncontrolled
Yes: Control Unknown
Unknown
If Yes, Date and time of withdrawal of support:
Date:
Time:
(military time)
If Yes, Date and time agonal phase begins (systolic BP < 80 or O2 sat. < 80%):
Date:
Time:
(military time)
If Yes, Total urine output during OR recovery phase:
Measures Between Withdrawal of Support and Cardiac Death. Provide Serial Data Every 15 Minutes Between Withdrawal of Support and Start of Agonal Phase, and Every 5 Minutes Between Start of Agonal Phase and Cardiac Death.
Date:
Time:
Systolic blood pressure:
Diastolic blood pressure:
Mean arterial pressure:
O2 saturation:
If Yes, Core Cooling Used:
YES
NO
If Yes, Date and time of abdominal aorta cannulation:
Date:
Time:
(military time)
ST=
Missing
Unknown
N/A
Not Done
If Yes, Date and time of thoracic aorta cannulation:
Date:
Time:
(military time)
ST=
Missing
Unknown
N/A
Not Done
If Yes, Date and time of portal vein cannulation:
Date:
Time:
(military time)
ST=
Missing
Unknown
N/A
Not Done
If Yes, Date and time of pulmonary artery cannulation:
Date:
Time:
(military time)
ST=
Missing
Unknown
N/A
Not Done
If Yes, Estimated Warm Ischemic Time:
min
ST=
Missing
Unknown
N/A
Not Done
If DCD, date and time heart recovered/removed from donor:
Date:
Time:
(military time)
If DCD, date and time right lung recovered/removed from donor:
Date:
Time:
(military time)
If DCD, date and time left lung recovered/removed from donor:
Date:
Time:
(military time)
If DCD, date and time double/en-bloc lung recovered/removed from donor:
Date:
Time:
(military time)
If No, Was this a consented DCD donor that progressed to brain death?
YES
NO
Cardiac arrest since neurological event that led to declaration of brain death:
YES
NO
If Yes, Duration of Resuscitation:
min
ST=
Missing
Unknown
N/A
Not Done
History of previous MI:
YES
NO
UNK
LV ejection fraction (%):
%
ST=
Missing
Unknown
N/A
Not Done
Method:
Echo
MUGA
Angiogram
Structural Abnormalities
Valves:
YES
NO
Congenital:
YES
NO
LVH:
YES
NO
Wall Abnormalities
Segmental:
YES
NO
Global:
YES
NO
Coronary Angiogram:
No
Yes, normal
Yes, not normal
If Abnormal, # of Vessels with > 50% Stenosis:
Lung - Was pO2 done:
YES
NO
UNK
If Yes, Lung pO2:
mm/Hg
ST=
Missing
Unknown
N/A
Not Done
If Yes, Lung pO2 on FiO2 of:
pCO2:
mm/Hg
ST=
Missing
Unknown
N/A
Not Done
Was a pulmonary artery catheter placed:
YES
NO
Initial:
Final:
Map: (mm/Hg)
CVP: (mm/Hg)
PCWP: (mm/Hg)
SVR: (dynes/sec/cm)^5)
PA Systolic (initial)
PA Diastolic: (mm/Hg)
CO: (L/min)
Cardiac Index: (L/min/sq.m)
Biopsy (heart donors only):
NO
YES, MYOCARDITIS
YES, NEGATIVE BIOPSY RESULT
YES, OTHER DIAGNOSIS SPECIFY
If other, specify:
Left Lung Bronchoscopy:
No Bronchoscopy
Bronchoscopy Results normal
Bronchoscopy Results, Abnormal-purulent secretions
Bronchoscopy Results, Abnormal-aspiration of foreign body
Bronchoscopy Results, Abnormal-blood
Bronchoscopy Results, Abnormal-anatomy/other lesion
Bronchoscopy Results, Unknown
Unknown if bronchoscopy performed
Right Lung Bronchoscopy:
No Bronchoscopy
Bronchoscopy Results normal
Bronchoscopy Results, Abnormal-purulent secretions
Bronchoscopy Results, Abnormal-aspiration of foreign body
Bronchoscopy Results, Abnormal-blood
Bronchoscopy Results, Abnormal-anatomy/other lesion
Bronchoscopy Results, Unknown
Unknown if bronchoscopy performed
Chest X-ray:
No chest x-ray
Normal
Abnormal-left
Abnormal-right
Abnormal-both
Results Unknown
Unknown if chest x-ray performed
DONOR HLA TYPING
Typing Method Class I:
Serology
DNA
A (1):
A (2):
1
2
0201
0202
0203
0205
0206
3
9
10
11
1101
1102
19
23
24
2402
2403
25
26
28
29
2901
2902
30
3001
3002
31
32
33
3301
3303
34
3401
3402
36
43
66
6601
6602
68
6801
6802
69
74
80
No second antigen detected
Not Tested
1
2
0201
0202
0203
0205
0206
3
9
10
11
1101
1102
19
23
24
2402
2403
25
26
28
29
2901
2902
30
3001
3002
31
32
33
3301
3303
34
3401
3402
36
43
66
6601
6602
68
6801
6802
69
74
80
No second antigen detected
Not Tested
B(1):
5
7
0702
8
0801
0802
0803
0804
12
13
1301
1302
14
1401
1402
15
1501
1502
1503
1510
1511
1512
1513
1516
1517
16
17
18
21
22
27
2705
2708
35
37
38
39
3901
3902
3905
3913
40
4001
4002
4005
4006
41
42
44
4402
4403
4415
45
46
47
48
49
50
51
5101
5102
52
53
54
55
56
57
5701
5703
58
59
60
61
62
63
64
65
67
70
71
72
73
75
76
77
78
81
82
No second antigen detected
Not Tested
B (2):
5
7
0702
8
0801
0802
0803
0804
12
13
1301
1302
14
1401
1402
15
1501
1502
1503
1510
1511
1512
1513
1516
1517
16
17
18
21
22
27
2705
2708
35
37
38
39
3901
3902
3905
3913
40
4001
4002
4005
4006
41
42
44
4402
4403
4415
45
46
47
48
49
50
51
5101
5102
52
53
54
55
56
57
5701
5703
58
59
60
61
62
63
64
65
67
70
71
72
73
75
76
77
78
81
82
No second antigen detected
Not Tested
Typing Method Class II:
Serology
DNA
DR (1):
1
0101
0102
103
2
3
0301
0302
4
0401
0402
0403
0404
0405
0407
5
6
7
8
9
0901
0902
10
11
1101
1104
12
1201
1202
13
1301
1303
14
1401
1402
1403
1404
1454
15
1501
1502
1503
16
1601
1602
17
18
No second antigen detected
Not Tested
DR (2):
1
0101
0102
103
2
3
0301
0302
4
0401
0402
0403
0404
0405
0407
5
6
7
8
9
0901
0902
10
11
1101
1104
12
1201
1202
13
1301
1303
14
1401
1402
1403
1404
1454
15
1501
1502
1503
16
1601
1602
17
18
No second antigen detected
Not Tested
DONOR PROCUREMENT AND CONSENT
Date and time of pronouncement of death: (Complete for brain dead and DCD donors):
Date:
Time:
(military time)
Date and time consent obtained for first organ:
Date:
Time:
(military time)
ORGAN RECOVERY
Recovery Date (donor to OR):
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