🏥 LT Data Entry Suite

Patient Name

UHID

DOB/Age

Sex

Blood Grp

Diagnosis

Etiology

Transplant Type

Graft Type

Partial Graft Type

ABOi (Y/N)

MELD

DOS (DD-MM-YYYY)

Surgeon

Donor Name

Donor UHID

Donor Graft Wt(g)

GRWR

Outcome

Status

Days Alive (auto)

Last Follow-up

Total Follow-ups

Patient Identifiers

Patient Name

UHID

DOS (DD-MM-YYYY)

Adult/Paediatric

Age (yrs)

Sex

Height (cm)

BMI (auto) AUTO

Wt at Eval (kg)

Recipient Blood Grp

Donor Reference

Donor Name

Donor UHID

Donor Age

Donor Sex

Donor Blood Group

Donor Height (cm)

Donor Weight (kg)

Donor BMI (auto) AUTO

Diagnosis & Severity

Etiology

Describe Etiology

Indication

Presentation

CTP Score

MELD at Listing

MELD-Na

PELD

History & Examination

Chief Complaint / Index Presentation

Performance Status (PS)

Pulse (P)

Pedal Edema (PE)

SpO2 (% on room air)

P/A Findings

HCC & Tumour

HCC?

Within Milan?

Within UCSF?

Downstaging?

Downstaging Type

Initial AFP

Initial PIVKA-II

Pre-TX AFP

Pre-TX PIVKA-II

Tumour Biology

PVTT

Transplant Plan

Type of TX

Type of Graft

Type of Partial Graft

Graft Modification

ABOi (auto) AUTO

ABOi Protocol Started?

Special Notes

Lab — Haematology & Coagulation

Date of Labs

Hb (g/dL)

TLC (cells/µL)

Platelets (×10³)

PT (sec)

INR

APTT (sec)

Fibrinogen (mg/dL)

Lab — Liver Function

Total Bili (mg/dL)

Direct Bili (mg/dL)

SGOT (U/L)

SGPT (U/L)

ALP (U/L)

Total Protein (g/dL)

Albumin (g/dL)

Globulin (g/dL)

Lab — Renal & Electrolytes

Creatinine (mg/dL)

Na (mEq/L)

K (mEq/L)

Calcium (mg/dL)

Phosphorus (mg/dL)

Mg (mg/dL)

FBS (mg/dL)

HbA1c (%)

Blood Urea (mg/dL)

Lab — Thyroid & Lipids

T3 (ng/dl)

T4 (mcg/dl)

TSH (mIU/ml)

TC (mg/dl)

HDL (mg/dl)

LDL (mg/dl)

TG (mg/dl)

Lab — Iron Studies & Special

Iron (mcg/dl)

TIBC (mcg/dl)

Ferritin (ng/ml)

Transferrin Sat (%)

Ceruloplasmin (µmol/L)

ANA

IgG (g/L)

AFP (ng/mL)

CA 19-9 (U/mL)

PSA (ng/mL)

CEA (ng/mL)

Lab — Serology

HBsAg

HBcAb Total

HBV DNA

Anti-HCV

VDRL/RPR

HIV 1&2

CMV IgM

CMV IgG

G6PD (U/g Hb)

DCT

ICT

UPCR

🔁 Repeat Labs (CBC / RFT / LFT / Lipid Profile — log every time repeated, with date)

Date

Panel

Values

Cultures

Cultures Done?

Blood Culture

Urine Culture

Ascitic Fluid TLC

Ascitic ADA (IU/L)

Ascitic Protein (g/dL)

Imaging

USG Liver

CT Artery/Celiac

CT Portal Vein

CT Caudate Wrap

CT Collaterals

CT Spleen

CT Pleural Effusion

Endoscopy Finding

📎 USG Abdomen Report

📎 CT Scan Image

📎 Urine Routine Report

📎 Chest X-Ray

Pulmonary & ABG

FVC (L)

FEV1 (L)

FEV1/FVC (%)

ABG pH

ABG pO2

ABG pCO2

ABG HCO3

ABG Base Excess (BE)

ABG Lactate

Date of PFT

Cardiology

ECG Finding

2D Echo EF (%)

2D Echo RVSP (mmHg)

2D Echo TR Grade

2D Echo RWMA

2D Echo Diastolic Dysf

DSE

Bubble Contrast Echo

Coronary Angiogram

Cardiology Risk

Cardiology Opinion

Clearances & Fitness

Cardiology Clearance

Psychiatry Clearance

Anaesthesia Clearance

Hepatology Clearance

Pulmonology Clearance

Issues/Concerns

Fitness for OLT

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Operating Centre & Patient

Operating Centre

Patient Name

UHID

Month & Year

DOS (DD-MM-YYYY)

Adult/Paediatric

Age

Sex

Wt at Surgery (kg)

Height (cm)

BMI at Surgery AUTO

Wt at Evaluation (kg)

BMI at Evaluation AUTO

Recipient Clinical

Recipient Blood Grp

Donor Blood Grp

ABOi AUTO

Etiology

Describe Etiology

Indication for Transplant

Presentation

CTP Score (Adult)

MELD at Listing

MELD at Surgery

PELD

HCC?

🧪 Pre-op Labs

Pre-op Bili (mg/dL)

Pre-op Creat (mg/dL)

Pre-op INR

Sodium (mEq/L)

Starting Hb (g/dL)

🚶 Frailty Assessment

LFI

6MWT (%pred)

6MWT Dist (m)

Hand Grip (kg)

SPPB

🏥 Status Before TX

Status Before TX

Recent Admit <4wks?

AKI Last Month

HE Last Month

SBP Last Month

🫁 Organ Support

Intraop Details — TX Type & Team

Type of TX

Type of Graft

Type of Partial Graft

Senior Surgeon

1st Assistant

2nd Assistant

Anaesthesiologist

Donor & Graft

Donor Name

Donor UHID

Relationship Category

Actual Relation

Donor Age

Donor Gender

Donor Weight (kg)

Donor BMI AUTO

Operative Times (24-hour format)

Incision Time

Portal Vein Clamp Time

Native Liver Out Time

Graft Out of Ice Time

Liver Out of Ice Time

Portal Reperfusion Time

Arterial Reperfusion Time

BD Anastomosis Time

Closure Time

Operative Time (min, auto)

CIT (min, auto)

WIT2 (min, auto)

Anhepatic Time (min)

IVC Clamp Time (min)

Hepatectomy & Findings

Ascites Type

Ascites Vol (mL)

Portal Hypertension

PV Thrombosis (Yerdel)

Adhesions

Problems During Recipient Hepatectomy

Portacaval Shunt (PCS)?

PCS Duration (min)

Outflow Reconstruction

RL - Outflow Type

Anterior Sector Reconstructed Using

PTFE Size

V5 No. Reconstructed

V8 No. Reconstructed

IRHV Expected

IRHV in Graft

IRHV Closed

IRHV for Reconstruction

LL Outflow Plasty?

LL Outflow Patch?

S3 Vein Reconstructed?

Outflow Needs Patch?

Any Septoplasty?

Whole/Cadaveric Graft — Outflow Anastomosis Type

Venous Conduit / Iliac Vein Graft (if used)

Conduit Used?

Date of Collection

Source Hospital

C/S Sent?

HV Anastomosis

IRV Management / Outflow LLS/LL

Anastomoses — Portal Vein

No. of Portal Veins in Graft

PV Reconstruction?

PV Anastomosis

Paediatric PV Anastomosis

Conduit Used

Portal Thrombectomy Details

Portal Inflow Modulation

Other Inflow Modulation Details

Anastomoses — Artery & Bile Duct

Arteries Anastomosed

Artery Conduit?

Recipient Artery Used

Quality of Recipient Artery

Bile Ducts in Graft

Bile Duct Size

Recipient Duct Used

BD Anastomosis — Duct 1

BD Stent?

Stent Material & Duct

No of Stents

Graft Weight & GRWR

Graft Appearance

Position of BD to Artery

Intra-op Bile Production

Additional Procedures

Final GW (g)

Expected GW (g)

Final GRWR AUTO

Expected GRWR AUTO

Reperfusion & Blood Products

Reperfusion Syndrome

Solumedrol Dose at Reperfusion

Blood Loss (mL)

PRC (Units)

PRC (mL)

FFP (mL)

SDP (mL)

Cryo (mL)

Inotrope Support at Shifting

Inotrope Dose

Urine Output (mL)

Crystalloids (mL)

Peak Lactate

End Lactate

Portal Pressures & Doppler

Portal P Pre-Reperfusion

Portal P Post-Reperfusion

Portal P Post-Modulation

Doppler HV

Doppler HA

Doppler PV

Complications & Closure

Intraop Complications / Significant Events

Closure Method

ABOi Protocol

ABOi

Titre IgM - Baseline

Titre IgG - Baseline

CD19 Baseline

CD20 Baseline

Rituximab Given?

Rituximab Date

No. of Doses of Rituximab

Rituximab Total Dose

Rituximab Dose/BSA

Post-Rituximab Titre IgM

Post-Rituximab Titre IgG

Post-Rituximab CD19

Post-Rituximab CD20

Pre-TX PLEX Done?

No. of Cycles of PLEX

Glycosorb Used?

Pre-TX Titre Day of Surgery - IgM

Pre-TX Titre Day of Surgery - IgG

Days Between Rituximab & TX

HCC Details

Within Milan

Within UCSF

Downstaging?

Type of Downstaging

Initial AFP

Initial PIVKA-II

Pre-TX AFP

Pre-TX PIVKA-II

Biology

PVTT

📄 OT Note — Document-Only Fields

Consultants

Date of Procedure

Scrub Nurses

OR Number

Comorbidities

History of Present Illness

Findings (Explant)

Liver

Tumor

Spleen

Small Bowel

Hernia

Surgeon per Operative Step

Explant Hepatectomy by

Bench Work by

HV Anastomosis by

PV Anastomosis by

HA Anastomosis by

BD Anastomosis by

Bench Work & Implantation Details

Perfusion Volume (mL UW)

Lowest BP (mmHg)

PV Velocity (cm/s)

HA Resistive Index

HA Peak Systolic Velocity

Fibrinogen Concentrate/PCC Used

✏️ Anatomy / Implant Diagram (draw freehand)

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Identifiers & Stay

Patient Name

UHID

DOS (DD-MM-YYYY)

DOD (DD-MM-YYYY)

Hospital Stay (days)

ICU Stay (days)

ICU Readmission?

Final Outcome

Wt at Discharge (kg)

Early Graft Function

Day 7 Bili

Day 7 INR

Day 14 Bili

Day 14 INR

Day 7 Ascites

Day 14 Ascites

Peak ALT (IU/L, within 7 days)

Peak AST (IU/L, within 7 days)

EAD (Olthoff, auto) AUTO

IPF

PNF

SFSS

Vascular & Biliary Complications

HAT

PVT

Outflow Complication

Bile Leak

Biliary Stricture

Post-op Haemorrhage

DIC

Re-transplantation

Immunosuppression

Induction

Induction Details

IS Modification?

IS Modification Details

Biopsy Done?

Biopsy Report

Rejection Episode?

Rejection Management

Rejection Outcome

Respiratory

Ventilator Days

Re-intubation?

Tracheostomy?

Chest Infections

HFNC Used?

Cardiovascular

Post-op Inotropes?

Inotrope >24hr?

Arrhythmias?

Coronary Events?

Renal

Pre-op Renal Dysfunction?

Post-op Renal Dysfunction?

RRT?

Type of RRT

Duration RRT

GI & Nutrition

Day Orals Started

Delay in Orals?

NG/NJ Feeds?

PN?

Days PN

GI Bleed?

Prolonged Ileus?

Endoscopy?

VTE & Miscellaneous

DVT?

PE?

Chyle Leak?

Perihepatic Collection?

Liver Abscess?

Wound

Sup Wound Infection?

Deep Wound Infection?

Wound Dehiscence?

Wound at Discharge

Procedures & Interventions

Percutaneous Intervention?

No. PERCUT Int

Biliary Int (ERCP/PTC)?

No. Biliary Int

Re-explorations?

No. Re-explorations

Indication Re-surgery

Findings Re-exploration

Procedure Done

Neurological

Seizures?

Intracranial Bleed?

Infections

Pre-op Infection (<2wks)?

MDR C/S?

Site MDR

CMV Disease?

Fungal Infection?

C.diff Colitis?

Post-intraop Culture

Summary

Final Clavien Score

Reason for Score Selected

Additional Notes

📄 Discharge Summary — Document-Only Fields

Consultants

Donor Reference (name_UHID)

Date of Transplant

History of Present Illness

HIV

HbsAg

HCV

Anti HBS

Donor CMV IgG

Recipient CMV IgG

Post-op Course Timeline

Extubated After (hrs)

Oxygen Weaned POD

Ward Transfer POD

Foley Removed POD

Left Drain Removed POD

Right Drain Removed POD

Immunosuppression Details

Induction Dose

Steroid Taper Start

Tacrolimus Start Dose/Day

1st TAC Level

MMF Start Day

Discharge Tacrolimus Dose

Discharge MMF Dose

Discharge Lab Trend

Hb — POD1

Hb — Peak/Lowest

Hb — Discharge

TC — POD1

TC — Peak

TC — Discharge

Platelet — POD1

Platelet — Lowest

Platelet — Discharge

Na/K — POD1

Na/K — Peak

Na/K — Discharge

Creatinine — POD1

Creatinine — Peak

Creatinine — Discharge

ALT — POD1

ALT — Peak

ALT — Discharge

AST — POD1

AST — Peak

AST — Discharge

Drains — POD1

Drains — Peak

Drains — Discharge

Condition at Discharge

Right Pleural Effusion

Temp

PR

BP

SpO2

Abdomen

Wound

📎 Blood Test Chart / Trend

Discharge Instructions

Medications — free-text fallback (used only if no structured entries below)

Medications — Structured Table (S.No / Category / Drug / Dose / Timing / Notes)

🏥 LT Data Entry Suite

🏥 Liver Transplant — Data Entry Suite

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