Hospital Routine Inquiry For Organ Donation
| Date: | December 6, 1995 |
| Pages: | 1 |
HOSPITAL ROUTINE INQUIRY FOR ORGAN DONATION
A. PATIENT'S NAME McPherson, Lisa ?
CHART NO 37128606
PATIENT'S AGE: ?
SEX: F
DATE OF DEATH: 12-5/95
ETHNICITY: BLACK ___ HISPANIC ___ AMERICAN INDIAN ___ WHITE _X_ ASIAN ___ OTHER ___
B. NAME OF NEXT OF KIN: ?
2. LIFELINK CALLED: 1-800-XXX-XXXX) W/TIME: 2350 12/5/95
3. REQUESTOR'S NAME AND TITLE: Margo
A. PATIENT MEDICALLY SUITABLE TO BE CONSIDERED AS A POTENTIAL DONOR:
YES: ___ NO: _X_ IF NO, REASON: ME Case
B. REQUEST MADE: YES: ___ NO: _X_ IF NO, REASON: ME Case
C. IF YES, WAS CONSENT GIVEN: YES ___ NO ___
IF CONSENT NOT GIVEN, REASON:
CONTACT W/NEXT OF KIN:
___ ATTEMPTED, COULD NOT BE FOUND.
___ REFUSED CONSENT FOR DONATION
D. MEDICAL EXAMINER'S RELEASE REQUIRED: YES _X_ NO ___
MEDICAL EXAMINER'S OFFICE CONTACTED: YES _X_ NO ___
DATE & TIME OF CONTACT: 12/5/95 2350
NAME OF PERSON SPOKE WITH: Debbie
MEDICAL EXAMINER'S RELEASE OBTAINED: YES ___ NO _X_
MEDICAL EXAMINER'S AUTHORIZING RELEASE: __________
E. ORGANS OR TISSUES DONATED:
ORGANS OBTAINED: YES ___ NO _X_
TISSUES OBTAINED: YES ___ NO _X_
REQUESTOR'S SIGNATURE [signature] DATE: 12/5/95
COPIES: WHITE: MEDICAL RECORDS/YELLOW:
PROCUREMENT/PINK: ADMINISTRATION
ON COMPLETION DO NOT SEPARATE FORM**
COLUMBIA NEW PORT RICHEY HOSPITAL/NURSING DEPARTMENT CH333