Introduction: As medical acuity of pediatric liver transplant was noted to increase at our institution, a streamlined approach to exception narrative writing, in accordance with guidance from the Organ Procurement and Transplantation Network (OPTN), was developed to make access to solid organ transplant more equitable among patients with similar levels of medical urgency.

Method: A standardized note template was developed to include categories for providers to document specifics on areas that may or may not qualify as opportunities to get exception scores from the OPTN. These categories included complications of liver disease such as growth failure, infections, complications of portal hypertension, encephalopathy, hepatopulmonary syndrome, developmental delay, pruritis, and metabolic bone disease.

Results: The standardized note template was implemented via the electronic medical record for both inpatient and outpatient use in May 2022. The template was utilized in 18 of 19 patients evaluated. Of these patients, nine notes were used to support MELD/PELD exceptions with subsequent approval by the UNOS National Liver Review Board. Five patients did not require exception narrative writing due to dual organ listing, not proceeding to listing, or were transplanted at their natural score. The remaining 5 patients in which the template was used, are currently undergoing exception writing.

Conclusion: Standardization of the liver transplant evaluation note with streamlined documentation of complications of liver disease has proven successful in obtaining MELD/PELD exceptions for higher acuity patients who would not otherwise benefit from standard MELD/PELD score, with improved equity among patients with similar levels of medical urgency.