CMS SOM App. X, Tag X-087

Transplant programs must maintain up-to-date and accurate patient management records

for each patient who receives an evaluation for placement on a program’s waiting list and

who is admitted for organ transplantation.

Guideline §482.94(c)

Complete medical records must be maintained for all patients who have chosen to undergo all or

any portion of the evaluation process. Transplant programs are expected to define the structure

of their evaluation processes and ensure that it maintains documentation of any patient that

receives services from the transplant program.

Transplant programs are also expected to maintain documentation of each patient who is referred

to their program for transplantation as a potential treatment for their organ failure. For example,

this could be a referral from a medical physician, or it could be a potential candidate who is

requesting an evaluation by the program for consideration for transplantation. The program must

be able to show evidence of the plans for transplant and any determinations that are made for

placing the patient on the program’s waiting list, or if the referral is not appropriate for

transplantation based on the program’s criteria.