Organ Chart Qa Checklist - Organ Donation Alliance

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Organ Chart QA Checklist
T#
REF#
UNOS#
Donor:
ODC
Referral (LifeLogics)
Comments:
Demographics
Admission
Labs
NOK/ME
Disposition
Approach
Organ Referral Summary
Organ Consent Information
Upload Scans
Check for correctness/completion on the following paper forms:
DAL-Organ (#002)
Hemodilution Worksheet
Labels
Serology Form/Report(s)
Consent/Consent Checklist
10cc RTT included for archive
Registry Doc
ABO Confirmation (x2)
Medical Social History
Sub-typing for A blood types
Death Pronouncement
HLA Form/Report
Hospital Chart
Cross-match Results
Anesthesia Worksheet (#007)
Billing Memorandum
Operative Report (#008)
Organ Recovery Personnel (#028)
Biopsy Report (if applicable)
Hospital Personnel (#016)
High Risk Form
Family Letters (if applicable)
Staff Letters
NAT Testing Results
Standing Orders
Sympathy Card
Hospital Cultures
Recipient Information
Autopsy/MEIR Report
Asystolic Flowsheet
Misc Correspondence
Pulsatile Perfusion Record
Hospital Face Sheet
Check upload scans versus paper copies
Have all procured organs been consented? Yes
No
Research consented? Yes
No
AOPO Donor Form
Demographics/Death Info
Comments:
Cross-documentation of HLA
Admission Course
Comments:
Physical Assessment
Comments:
Pre-Mgmt Hemodynamics
Comments:
Pre-Mgmt I/O
Comments:
Labs
Comments:
All donors:
Electrolytes
Serum Glucose
Kidney donors:
Creatinine
BUN
Liver donors:
AST
ALT
Alkaline Phosphate
Direct Bili
Total Bili
PT/INR
PTT
Panc donors:
Serum Amylase
UA/CBC
Comments:
All donors:
UA within 24hrs of cross-clamp
CBC
CDS Form #706
Revision Date: 4/29/10
Effective Date: 5/17/10

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