Emergency Department RHC Checklist

Date:December 6, 1995
Pages:1

EMERGENCY DEPARTMENT RHC CHECK LIST

1. TIME OF RHC: 2151

2. DOCTOR TO SIGN DEATH CERTIFICATE: ________

PHONE NO: ________________

COMMENTS: ________________

3. ORGAN DONATION FORM COMPLETED: YES _X_ NO ___

4. LIFELINK NOTIFIED: 1-800-XXX-XXXX YES _X_ NO ___

5. MEDICAL EXAMINER NOTIFIED: 813-XXX-XXXX YES _X_ NO ___

6. FAMILY NOTIFIED: YES ___ NO _X_

NAME & PHONE NUMBER OF PERSON NOTIFIED: _________________

7. VALUABLES: none

GIVEN TO: _____________________

8. FUNERAL HOME: _____________________

NOTIFIED BY & TIME: _____________________

RELEASE SIGNED: YES ___ NO ___

9. TIME BODY TO MORGUE: _____________________

10. IF DOA/TRAUMA: POLICE AGENCY NOTIFIED: YES _X_ NO ___

AGENCY'S NAME & OFFICER'S NAME:

J. Perez, NPR PD

NURSE'S SIGNATURE:

[signature]

COLUMBIA NEW PORT RICHEY HOSPITAL<

NURSING DEPARTMENT

CH321 r3/95

MCPHERSON LISA