Sample # _____ Organs Recovered: Heart X-clamp date/time: ________________________ Lung Intestines 2.2 Evaluation of ALL Donors 2.2.1 Death pronounced ⁭ 2.2.2.1 Donor ID # ______________ HIGHLIGHT DEFICIENT AREAS IN PINK Medical/behavioral history ⁭ Med. cond. that may affect donated organ function ⁭ Presence of transmissible disease and/or malignancies⁭ ↑ risk of disease transmission, incl. blood borne pathogens HIV, Hep B, and Hep C (USPHS ↑ risk) ⁭ Risk of prion disease due to prior exposure or receipt of non- recombinant HPDGH ⁭ Kidney Pancreas Liver 2.2.4.4 Heart donors: 12 Lead ECG ⁭ Cardiology consult and/or Echo ⁭ 2.2.4.5 Pancreas donors: Amylase ⁭ 2.2.4.6 Lung donors: Sputum gram stain ⁭ 2.2.5 Follow-up donor testing (01/10/11) Cultures (post recovery positive results) blood Communication of this history documented, if applicable (policy updated 1/10/11) ⁭ 2.2.2.2 Medical record reviewed ⁭ 2.2.2.3 Physical exam performed ⁭ urine sputum other Serologies Other Reported to transplant centers within 24 hours ⁭ 2.2.3 Screening potential organ donors (01/10/11) Hemodilution calculation ⁭ CDC ↑ risk noted/communicated if hemodiluted? 2.2.6 Communicate to transplant program(s) any known or suspected infectious or neoplastic conditions that may be transmitted by the donor organ(s) ⁭ 2.3 Donor maintenance Complete history of all transfusions during admission ⁭ 2.2.3.2 2.2.4.1 FDA screening tests for HIV I/II (mandatory) ⁭ VS monitored and documented ⁭ Intake and output documented ⁭ ALL deceased donors: ABO Typing #1 ⁭ ABO Typing #2 ⁭ (3.2.4) 2/1/12 sub-typing X 2 if used for allocation (non A1) A sub-typing #1 ⁭ 2.4 Consent obtained ⁭ 2.5.3 Flush solutions A sub-typing #2 ⁭ pretransfusion samples ⁭ HBsAg ⁭ HBcAb ⁭ Anti-HCV ⁭ VDRL/ RPR (diagnostic ok) ⁭ Anti-CMV ⁭ EBV ⁭ 01/10/11 - all seros screening - not diagnostic assay type documented , if diagnostic ⁭ CBC ⁭ Electrolytes ⁭ Glucose ⁭ CXR ⁭ ABG’s ⁭ Blood Cultures ⁭ Urine Cultures ⁭ U/A within 24 hrs of XC ⁭ 2.2.4.2 Renal donors: BUN ⁭ 2.2.4.3 Liver donors: AST ⁭ ALT ⁭ Alk Phos ⁭ Total Bili ⁭ Direct Bili ⁭ INR ⁭ PTT ⁭ Flush Solutions recorded ⁭ Lot #s ⁭ Additives ⁭ Lot #s ⁭ Medication administration documented ⁭ 2.5.7 serum sample archived x 10 years (01/10/11) ⁭ 5.6.1 Labeling and documentation checked Creatinine ⁭ Miscellaneous other observations Revision date: August 15, 2012