Solid Organ Transplantation Abo/unos Id Confirmation Form

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Affix Recipient
Hospital Label/MRN Here
SOLID ORGAN TRANSPLANTATION
ABO/UNOS ID CONFIRMATION
Organ(s)
Donor UNOS ID
Heart
Liver
Heart-Lung
Split Liver
OPO
Lung(s)
Kidney(s)
Right
Pancreas
Recovery Team
Left
Small Bowel
Transplant MD
Both
Other
ABO:
Recipient ABO/Rh
Donor ABO/Rh
T. Cruzi Ab
Donor Serologies:
HIV
HCV
HBsAg
HBcAb
CMV IgM
EBV IgM
/
/
:
Verified by
Date
Time
Verified by
Date
/
/
Time
:
The donor and recipient ABOs must be verified for compatibility or planned incompatibility prior to organ recovery. 2
team members, or 1
team member and 1
OPO representative, must sign/date/time prior to organ recovery.
UNOS ID Number:
Confirm that UNOS ID on organ(s)/chart/specimens matches Transplant Report Sheet
ABO Compatibility:
Donor ABO/Rh
Recipient ABO/Rh
Recipient and donor are ABO identical - OK to proceed
Recipient and donor are ABO compatible - OK to proceed
Group A recipients can receive Group A or Group O organs.
Group B recipients can receive Group B or Group O organs.
Group AB recipients can receive Group AB, A, B, or O organs.
Recipient and donor are ABO incompatible - CAUTION!!!
Verified by
Date
/
/
Time
:
/
/
:
Verified by
Date
Time
Verification of UNOS ID and donor/recipient ABO must take place prior to organ implantation. The transplanting surgeon (attending or fellow) and one other licensed team
member must sign/date/time prior to organ implantation. If the transplanting surgeon is already scrubbed in he/she must verify the UNOS ID and ABOs with the circulator,
who can date/time on behalf of the surgeon. The surgeon can then sign upon completion of the transplant.
If the organ(s) has been recovered by another center the “organ recovery team” signatures in the top portion of this form should be left blank.
Notify
Transfusion Medicine (
) of any adverse effects, disease transmission,
or other suspected complications attributed to the solid organ/tissue.
Revised 08/2009

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