31 Intestine Transplant Recipient Registration_Form.xlsx

TRR - Intestine - 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	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	Secondary Diagnosis	Not required		4-Patient Status	Secondary Diagnosis	Not required
4-Patient Status	Secondary Diagnosis//Specify	Not required		4-Patient Status	Secondary Diagnosis//Specify	Not required
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	Not required		4-Patient Status	Date of Discharge from Tx Center	Not required
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	Ventilator			4-Patient Status	Ventilator
4-Patient Status	Artificial Liver			4-Patient Status	Artificial Liver
4-Patient Status	Other Mechanism			4-Patient Status	Other Mechanism
4-Patient Status	Other Mechanism, Specify			4-Patient Status	Other Mechanism, Specify
4-Patient Status	Functional Status			4-Patient Status	Functional Status
4-Patient Status	Working for income			4-Patient Status	Academic Progress
4-Patient Status	Primary Source of Payment			4-Patient Status	Academic Activity Level
4-Patient Status	Primary Source of Payment, Specify			4-Patient Status	Primary Source of Payment
5- Pretransplant	Height			4-Patient Status	Primary Source of Payment, Specify
5- Pretransplant	Height in Centimeters//Status	Value or status is reported, not both		4-Patient Status	Cognitive Development
5- Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only		4-Patient Status	Motor Development
5- Pretransplant	Weight			5- Pretransplant	Date of Measurement
5- Pretransplant	Weight in Kilograms//Status	Value or status is reported, not both		5- Pretransplant	Height
5- Pretransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only		5- Pretransplant	Height in Centimeters//Status	Value or status is reported, not both
5- Pretransplant	BMI	Display Only - Cascades from Database		5- Pretransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only
5- Pretransplant	BMI://%ile	Calculated for display only		5- Pretransplant	Weight
5- Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database		5- Pretransplant	Weight in Kilograms//Status	Value or status is reported, not both
5- Pretransplant	Previous Transplant Date	Display Only - Cascades from Database		5- Pretransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only
5- Pretransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database		5- Pretransplant	BMI	Display Only - Cascades from Database
5- PreTransplant	HIV Serostatus			5- Pretransplant	BMI://%ile	Calculated for display only
5- PreTransplant	NAT HIV			5- Pretransplant	Previous Transplant Organ	Display Only - Cascades from Database
5- PreTransplant	CMV Status			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 Antibody Total			5- PreTransplant	HIV Serostatus
5- PreTransplant	HBV Surface Antigen			5- PreTransplant	NAT HIV
5- PreTransplant	NAT HBV			5- PreTransplant	CMV Status
5- PreTransplant	HCV Serostatus			5- PreTransplant	HBV Core Antibody
5- PreTransplant	NAT HCV			5- PreTransplant	HBV Surface Antibody Total
5- PreTransplant	EBV Serostatus			5- PreTransplant	HBV Surface Antigen
5-Pretransplant	Total Bilirubin			5- PreTransplant	NAT HBV
5-Pretransplant	Total Bilirubin//Status	Value or status is reported, not both		5- PreTransplant	HCV Serostatus
5-Pretransplant	Serum Albumin			5- PreTransplant	NAT HCV
5-Pretransplant	Serum Albumin//Status	Value or status is reported, not both		5- PreTransplant	EBV Serostatus
5-Pretransplant	Serum Creatinine			5-Pretransplant	Total Bilirubin
5-Pretransplant	Serum Creatinine//Status	Value or status is reported, not both		5-Pretransplant	Total Bilirubin//Status	Value or status is reported, not both
6-Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback		5-Pretransplant	Serum Albumin
6-Transplant Procedure	Intestine Venous Drainage			5-Pretransplant	Serum Albumin//Status	Value or status is reported, not both
6-Transplant Procedure	Native Viscera Venous Drainage			5-Pretransplant	Serum Creatinine
6-Transplant Procedure	Procedure Type	Display Only - Cascades from feedback		5-Pretransplant	Serum Creatinine//Status	Value or status is reported, not both
6-Transplant Procedure	Stomach			6-Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback
6-Transplant Procedure	Small Intestine			6-Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback
6-Transplant Procedure	Duodenum			6-Transplant Procedure	Intestine Venous Drainage
6-Transplant Procedure	Large Intestine			6-Transplant Procedure	Native Viscera Venous Drainage
6-Transplant Procedure	Total Ischemic Time (include cold, warm and anastomotic time)			6-Transplant Procedure	Procedure Type	Display Only - Cascades from feedback
6-Transplant Procedure	Total ischemia Time Hours (include cold, warm and anastomotic time)//Status	Value or status is reported, not both		6-Transplant Procedure	Stomach
6-Transplant Procedure	Recent Septicemia			6-Transplant Procedure	Small Intestine
6-Transplant Procedure	Exhausted Vascular Access			6-Transplant Procedure	Duodenum
6-Transplant Procedure	Previous Abdominal Surgery			6-Transplant Procedure	Large Intestine
6-Transplant Procedure	Dilated/Non-Functional Bowel Segments			6-Transplant Procedure	Total Ischemic Time (include cold, warm and anastomotic time)
6-Transplant Procedure	Other risk factors	Not required		6-Transplant Procedure	Total ischemia Time Hours (include cold, warm and anastomotic time)//Status	Value or status is reported, not both
7- Post Transplant	Graft Status			6-Transplant Procedure	Recent Septicemia
7- Post Transplant	TPN Dependent			6-Transplant Procedure	Exhausted Vascular Access
7- Post Transplant	IV Dependent			6-Transplant Procedure	Previous Abdominal Surgery
7- Post Transplant	Oral Feeding			6-Transplant Procedure	Dilated/Non-Functional Bowel Segments
7- Post Transplant	Tube Feed			6-Transplant Procedure	Other risk factors	Not required
7- Post Transplant	Date of Graft Failure			7- Post Transplant	Graft Status
7- Post Transplant	Primary Cause of Graft Failure			7- Post Transplant	TPN Dependent
7- Post Transplant	Primary Cause of Graft Failure//Specify			7- Post Transplant	IV Dependent
7 - PostTransplant	Did patient have any acute rejection episodes between transplant and discharge			7- Post Transplant	Oral Feeding
10- Immunosupression Other	Are any medications given currently for maintenance or anti-rejection			7- Post Transplant	Tube Feed
9- Immunosupression Other	immunosuppression medication			7- Post Transplant	Date of Graft Failure
9- Immunosupression Other	immunosuppression medication indication			7- Post Transplant	Primary Cause of Graft Failure
9- Immunosupression Other	days of induction			7- Post Transplant	Primary Cause of Graft Failure//Specify
				7 - PostTransplant	Did patient have any acute rejection episodes between transplant and discharge
	Public Burden Statement			10- 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