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Hospital Peri-Operative Death Medical Examination Example
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HOSPITAL - PERI-OPERATIVE DEATH NAME OF DECEDENT: This form is to be completed in addition to the ROD form in these guidelines ATTENDING PHYSICIAN: INFORMANT: WAS THIS ADMISSION SCHEDULED OR AN EMERGENCY? WHAT WAS ADMISSION TIME & DATE: THE DECEDENT LENGTH OF TIME DECEDENT WAS KNOWN TO HAVE HAD DISEASE OR INJURY PRIOR TO
PROCEDURE TO CORRECT IT: DID DECEDENT PUT PROCEDURE OFF UNTIL THE PROSPECTIVE SURVIVAL DECREASED? ROUTINE SURGERY IF THIS WAS ROUTINE OR ELECTIVE SURGERY), WAS THIS A REGULARLY SCHEDULED PROCEDURE FOR THE DECEDENT? SURGICAL PROCEDURE WAS CONSENT REQUESTED AND OBTAINED FOR THE PROCEDURE(S)? IF NO, EXPLAIN: WHO MADE THE REQUEST: TEL: WHO GRANTED: TEL: ADDRESS/CITY/STATE/ZIP: RELATIONSHIP TO THE DECEDENT: WHAT WAS/WERE SURGICAL PROCEDURE(S) - INCLUDE DATES/TIMES: IF PROCEDURE WAS PRESCHEDULED, WAS DECEDENT WARNED OF RISKS INVOLVED? IF SO, BY
WHOM AND WHEN: WERE FAMILY/DECEDENT WARNED OF THE RISKS INVOLVED? IF SO WHEN AND BY WHOM? WERE THESE WARNINGS DOCUMENTED ANYWHERE IN THE RECORDS? DID DECEDENT HAVE OTHER DIAGNOSED DISEASES/INJURIES NOT CONSIDERED TO BE AN
ADDITIONAL RISK TO THIS PROCEDURE? DID DECEDENT HAVE OTHER DIAGNOSED DISEASES/INJURIES THAT WOULD HAVE KNOWINGLY
INCREASED THE RISK OF THIS PROCEDURE? DID DECEDENT/FAMILY UNDERSTAND INCREASED RISK DUE TO ADDITIONAL DIAGNOSES? WERE ADDITIONAL DISEASES/INJURIES FOUND DURING THE PROCEDURE THAT WERE
PREVIOUSLY UNDIAGNOSED? HAD THESE DISEASES OR INJURIES BEEN KNOWN, WOULD THE PROCEDURE HAVE BEEN DONE
ANYWAY? IF ADDITIONAL DISEASE/INJURIES WERE FOUND DURING THE PROCEDURE, DID THIS DISCOVERY NEGATE OR CHANGE THE ORIGINALLY PLANNED PROCEDURE? PRE-OPERATIVE REPORT WERE ALL ROUTINE PRE -OPERATIVE LABORATORY TESTS ORDERED AND PERFORMED? WERE THE RESULTS AVAILABLE TO THE SURGICAL TEAM PRIOR TO THE PROCEDURE? WERE THEY REVIEWED BY THE SURGICAL TEAM? WERE THEY NORMAL FOR THE DECEDENT? WAS BLOOD TYPED AND CROSS -MATCHED PRIOR TO THE PROCEDURE? WAS THE BLOOD ORDERED FOR THIS PROCEDURE THE AMOUNT NORMALLY ORDERED FOR
SIMILAR TYPES OF SURGERY? DID THE DECEDENT HAVE ANY KNOWN ALLERGIES TO ANY MEDICATIONS? IF YES, WERE ANY OF
THEM USED IN THIS PROCEDURE? ANESTHESIA WERE PRE -ANESTHETIC AGENTS USED FOR THIS PROCEDURE? IF PRE -ANESTHETIC AGENTS WERE USED COMPLETE THE FOLLOWING: AGENT USED: AMOUNT: METHOD OF ADMINISTERING: DATE/TIME ADMINISTERED: ADMINISTERED BY: ANY UNTO WARD REACTION AT THE TIME OF ADMINISTRATION: USE ADDITIONAL PAGES TO LIST OTHERS. ARE ALL OF THESE AGENTS NORMALLY USED FOR THIS PROCEDURE? WHO ORDERED THESE AGENTS: WHEN: DOES THE PERSON WHO ADMINISTERED THE AGENTS ON THIS CASE NORMALLY ADMINISTER
PRE-ANESTHETIC AGENTS? EXPLAIN THE TERMINAL EVENT? WHAT RESUSCITATIVE OR HEROIC PROCEDURES WERE PERFORMED DURING THE TERMINAL
EPISODE?
IF THERE IS EVIDENCE OF MEDICAL MISADVENTURE, OBTAIN A COPY OF THE RISK MANAGEMENT REPORT FILED WITH THE HOSPITAL. SURGICAL AND/OR RECOVERY TEAM INDIVIDUAL INTERVIEWS NAME: DUTIES: WERE YOU AT YOUR STATION DURING THE ENTIRE PROCEDURE? WHAT WERE YOU DOING AT THE TIME? WERE THE REST OF THE TEAM AT THEIR STATIONS? HAS THIS SURGICAL TEAM PERFORMED SIMILAR PROCEDURES PREVIOUSLY? IS THIS OPERATING ROOM EQUIPPED ADEQUATELY FOR THIS PARTICULAR PROCEDURE? WERE THERE VISIBLE SYMPTOMS PRESENT WARNING OF THE UNTOWARD OR TERMINAL EVENT? WERE THESE SYMPTOMS RECOGNIZED AND THE PROCEDURE STOPPED OR ALTERED? WAS THE NECESSARY EQUIPMENT REQUIRED TO REVERSE THE UNTOWARD EVENT AVAILABLE IN
OR TO THE OPERATING ROOM? WAS IT USED? WHERE WAS IT KEPT? ARE YOU AWARE OF ANY COMPLAINTS OR REPAIR ORDERS FOR EQUIPMENT? HOW LONG DID IT TAKE TO UTILIZE THE EQUIPMENT? IF THIS IS AN UNUSUALLY LONG DELAY, EXPLAIN? NAME OF INVESTIGATOR DMI# ANESTHESIA (GIVE TOTAL DOSE OF ALL AGENTS, HOW ADMINISTERED, BY WHOM, TIME AND DATE) WHAT ANESTHESIA WAS USED/DOSE? 1. 2. 3. WHY WAS AGENT(S) SELECTED? INHALATION (DURATION AND MIXTURE, INCLUDING INDUCTIVE AGENTS)? SPINAL (AGENT, DILUENT, INJECTION SITE)? PARENTERAL (AGENT, DOSE, DRIP FLOW, LENGTH OF ADMINISTRATION, AND DILUENT)? MUSCLE RELAXANT (AGENT, METHOD OF ADMINISTRATION, DOSE, OBSERVED EFFECTS,
INCLUDING RESPIRATORY)? WHEN WAS THE ANESTHESIA STARTED (TIME & DATE): BY: ANY UNTOWARD REACTION WHEN THE ANESTHESIA WAS ADMINISTERED? WAS THE TIME PERIOD BETWEEN THE PRE -ANESTHESIA AGENT AND THE ADMINISTRATION OF
THE ANESTHESIA CONSIDERED NORMAL? IF THERE WAS AN UNUSUAL TIME DELAY, EXPLAIN: WAS ANY OTHER ANESTHETIC AGENT ADMINISTERED IN THE 48 HOURS PRIOR TO THIS
PROCEDURE? OPERATIVE REPORT LIST ALL PERSONS PRESENT IN THE OPERATING ROOM AND THEIR DUTIES: 1. , 2. , 3. , 4. , 5. , 6. , 7. , 8. , 9. , 10. , WHEN WAS THE PROCEDURE STARTED (TIME & DATE): WAS THE SUBJECT S TABLE AT THAT TIME? WAS THE TIME DELAY BETWEEN THE START OF THE ANESTHESIA AND THE START OF THE
PROCEDURE CONSIDERED NORMAL? WAS THE SUBJECT SATISFACTORILY ANESTHETIZED FOR THE PROCEDURE? WHAT IS THE USUAL DURATION OF THIS PROCEDURE? HOW LONG DID THIS PARTICULAR PROCEDURE TAKE? IF DIFFERENT FROM THE USUAL TIME, EXPLAIN: AT THE TIME THE PROCEDURE WAS STARTED WERE ALL OF THE FLUID INFUSIONS RUNNING
PROPERLY? DID ANY OF THE FLUID INFUSIONS OR TRANSFUSIONS DEVELOP PROBLEMS DURING THE
PROCEDURE? IF THERE WERE FLUID INFUSIONS OR TRANSFUSIONS USED DURING THE PROCEDURE, LIST THEM WITH TOTAL QUANTITY ADMINISTERED (ML.) AND THE RATE OF FLOW: 1. 2. 3. 4. 5. 6. WERE THERE ADDITIVES TO THE INFUSIONS? LIST THEM AND TOTAL AMOUNT OF EACH ADDED
AND ADMINISTERED: 1. 2. 3. WAS THERE AN EXCESSIVE AMOUNT OF HEMORRHAGE WITH THIS PROCEDURE? AT ANY TIME DURING THE CRITICAL PORTION OF THE PROCEDURE WERE THERE ANY
UNPLANNED DELAYS? AT ANY OTHER TIME DURING THE PROCEDURE WAS THERE A DELAY? EXPLAIN: WERE THERE ANY UNPLANNED CHANGES IN THE CRITICAL PORTION OF THE PROCEDURE? WERE THERE ANY UNPLANNED CHANGES DURING ANY OTHER PART OF THE PROCEDURE? WERE THERE ANY UNTOWARD OR UNEXPECTED EVENTS DURING THE PROCEDURE? IF THERE WERE ANY UNTOWARD OR UNEXPECTED EVENTS, EXPLAIN WHAT WAS DONE TO
CORRECT THEM OR WHAT ADDITIONAL PROCEDURES WERE INITIATED AS A RESULT, INCLUDING
HEROIC ATTEMPTS AT RESUSCITATION (IF RESPIRATORY OR CARDIAC ARREST, DURATION): WHAT TIME WAS THE PROCEDURE TERMINATED? DID THE SUBJECT LEAVE THE OPERATING ROOM IN A STABLE CONDITION? RECOVERY DID THE DECEDENT ARRIVE AT THE RECOVERY ROOM IN A STABLE CONDITION? WERE ANY ADDITIONAL PROCEDURES PERFORMED ON THE DECEDENT WHILE IN RECOVERY?
PROCEDURE TO CORRECT IT: DID DECEDENT PUT PROCEDURE OFF UNTIL THE PROSPECTIVE SURVIVAL DECREASED? ROUTINE SURGERY IF THIS WAS ROUTINE OR ELECTIVE SURGERY), WAS THIS A REGULARLY SCHEDULED PROCEDURE FOR THE DECEDENT? SURGICAL PROCEDURE WAS CONSENT REQUESTED AND OBTAINED FOR THE PROCEDURE(S)? IF NO, EXPLAIN: WHO MADE THE REQUEST: TEL: WHO GRANTED: TEL: ADDRESS/CITY/STATE/ZIP: RELATIONSHIP TO THE DECEDENT: WHAT WAS/WERE SURGICAL PROCEDURE(S) - INCLUDE DATES/TIMES: IF PROCEDURE WAS PRESCHEDULED, WAS DECEDENT WARNED OF RISKS INVOLVED? IF SO, BY
WHOM AND WHEN: WERE FAMILY/DECEDENT WARNED OF THE RISKS INVOLVED? IF SO WHEN AND BY WHOM? WERE THESE WARNINGS DOCUMENTED ANYWHERE IN THE RECORDS? DID DECEDENT HAVE OTHER DIAGNOSED DISEASES/INJURIES NOT CONSIDERED TO BE AN
ADDITIONAL RISK TO THIS PROCEDURE? DID DECEDENT HAVE OTHER DIAGNOSED DISEASES/INJURIES THAT WOULD HAVE KNOWINGLY
INCREASED THE RISK OF THIS PROCEDURE? DID DECEDENT/FAMILY UNDERSTAND INCREASED RISK DUE TO ADDITIONAL DIAGNOSES? WERE ADDITIONAL DISEASES/INJURIES FOUND DURING THE PROCEDURE THAT WERE
PREVIOUSLY UNDIAGNOSED? HAD THESE DISEASES OR INJURIES BEEN KNOWN, WOULD THE PROCEDURE HAVE BEEN DONE
ANYWAY? IF ADDITIONAL DISEASE/INJURIES WERE FOUND DURING THE PROCEDURE, DID THIS DISCOVERY NEGATE OR CHANGE THE ORIGINALLY PLANNED PROCEDURE? PRE-OPERATIVE REPORT WERE ALL ROUTINE PRE -OPERATIVE LABORATORY TESTS ORDERED AND PERFORMED? WERE THE RESULTS AVAILABLE TO THE SURGICAL TEAM PRIOR TO THE PROCEDURE? WERE THEY REVIEWED BY THE SURGICAL TEAM? WERE THEY NORMAL FOR THE DECEDENT? WAS BLOOD TYPED AND CROSS -MATCHED PRIOR TO THE PROCEDURE? WAS THE BLOOD ORDERED FOR THIS PROCEDURE THE AMOUNT NORMALLY ORDERED FOR
SIMILAR TYPES OF SURGERY? DID THE DECEDENT HAVE ANY KNOWN ALLERGIES TO ANY MEDICATIONS? IF YES, WERE ANY OF
THEM USED IN THIS PROCEDURE? ANESTHESIA WERE PRE -ANESTHETIC AGENTS USED FOR THIS PROCEDURE? IF PRE -ANESTHETIC AGENTS WERE USED COMPLETE THE FOLLOWING: AGENT USED: AMOUNT: METHOD OF ADMINISTERING: DATE/TIME ADMINISTERED: ADMINISTERED BY: ANY UNTO WARD REACTION AT THE TIME OF ADMINISTRATION: USE ADDITIONAL PAGES TO LIST OTHERS. ARE ALL OF THESE AGENTS NORMALLY USED FOR THIS PROCEDURE? WHO ORDERED THESE AGENTS: WHEN: DOES THE PERSON WHO ADMINISTERED THE AGENTS ON THIS CASE NORMALLY ADMINISTER
PRE-ANESTHETIC AGENTS? EXPLAIN THE TERMINAL EVENT? WHAT RESUSCITATIVE OR HEROIC PROCEDURES WERE PERFORMED DURING THE TERMINAL
EPISODE?
IF THERE IS EVIDENCE OF MEDICAL MISADVENTURE, OBTAIN A COPY OF THE RISK MANAGEMENT REPORT FILED WITH THE HOSPITAL. SURGICAL AND/OR RECOVERY TEAM INDIVIDUAL INTERVIEWS NAME: DUTIES: WERE YOU AT YOUR STATION DURING THE ENTIRE PROCEDURE? WHAT WERE YOU DOING AT THE TIME? WERE THE REST OF THE TEAM AT THEIR STATIONS? HAS THIS SURGICAL TEAM PERFORMED SIMILAR PROCEDURES PREVIOUSLY? IS THIS OPERATING ROOM EQUIPPED ADEQUATELY FOR THIS PARTICULAR PROCEDURE? WERE THERE VISIBLE SYMPTOMS PRESENT WARNING OF THE UNTOWARD OR TERMINAL EVENT? WERE THESE SYMPTOMS RECOGNIZED AND THE PROCEDURE STOPPED OR ALTERED? WAS THE NECESSARY EQUIPMENT REQUIRED TO REVERSE THE UNTOWARD EVENT AVAILABLE IN
OR TO THE OPERATING ROOM? WAS IT USED? WHERE WAS IT KEPT? ARE YOU AWARE OF ANY COMPLAINTS OR REPAIR ORDERS FOR EQUIPMENT? HOW LONG DID IT TAKE TO UTILIZE THE EQUIPMENT? IF THIS IS AN UNUSUALLY LONG DELAY, EXPLAIN? NAME OF INVESTIGATOR DMI# ANESTHESIA (GIVE TOTAL DOSE OF ALL AGENTS, HOW ADMINISTERED, BY WHOM, TIME AND DATE) WHAT ANESTHESIA WAS USED/DOSE? 1. 2. 3. WHY WAS AGENT(S) SELECTED? INHALATION (DURATION AND MIXTURE, INCLUDING INDUCTIVE AGENTS)? SPINAL (AGENT, DILUENT, INJECTION SITE)? PARENTERAL (AGENT, DOSE, DRIP FLOW, LENGTH OF ADMINISTRATION, AND DILUENT)? MUSCLE RELAXANT (AGENT, METHOD OF ADMINISTRATION, DOSE, OBSERVED EFFECTS,
INCLUDING RESPIRATORY)? WHEN WAS THE ANESTHESIA STARTED (TIME & DATE): BY: ANY UNTOWARD REACTION WHEN THE ANESTHESIA WAS ADMINISTERED? WAS THE TIME PERIOD BETWEEN THE PRE -ANESTHESIA AGENT AND THE ADMINISTRATION OF
THE ANESTHESIA CONSIDERED NORMAL? IF THERE WAS AN UNUSUAL TIME DELAY, EXPLAIN: WAS ANY OTHER ANESTHETIC AGENT ADMINISTERED IN THE 48 HOURS PRIOR TO THIS
PROCEDURE? OPERATIVE REPORT LIST ALL PERSONS PRESENT IN THE OPERATING ROOM AND THEIR DUTIES: 1. , 2. , 3. , 4. , 5. , 6. , 7. , 8. , 9. , 10. , WHEN WAS THE PROCEDURE STARTED (TIME & DATE): WAS THE SUBJECT S TABLE AT THAT TIME? WAS THE TIME DELAY BETWEEN THE START OF THE ANESTHESIA AND THE START OF THE
PROCEDURE CONSIDERED NORMAL? WAS THE SUBJECT SATISFACTORILY ANESTHETIZED FOR THE PROCEDURE? WHAT IS THE USUAL DURATION OF THIS PROCEDURE? HOW LONG DID THIS PARTICULAR PROCEDURE TAKE? IF DIFFERENT FROM THE USUAL TIME, EXPLAIN: AT THE TIME THE PROCEDURE WAS STARTED WERE ALL OF THE FLUID INFUSIONS RUNNING
PROPERLY? DID ANY OF THE FLUID INFUSIONS OR TRANSFUSIONS DEVELOP PROBLEMS DURING THE
PROCEDURE? IF THERE WERE FLUID INFUSIONS OR TRANSFUSIONS USED DURING THE PROCEDURE, LIST THEM WITH TOTAL QUANTITY ADMINISTERED (ML.) AND THE RATE OF FLOW: 1. 2. 3. 4. 5. 6. WERE THERE ADDITIVES TO THE INFUSIONS? LIST THEM AND TOTAL AMOUNT OF EACH ADDED
AND ADMINISTERED: 1. 2. 3. WAS THERE AN EXCESSIVE AMOUNT OF HEMORRHAGE WITH THIS PROCEDURE? AT ANY TIME DURING THE CRITICAL PORTION OF THE PROCEDURE WERE THERE ANY
UNPLANNED DELAYS? AT ANY OTHER TIME DURING THE PROCEDURE WAS THERE A DELAY? EXPLAIN: WERE THERE ANY UNPLANNED CHANGES IN THE CRITICAL PORTION OF THE PROCEDURE? WERE THERE ANY UNPLANNED CHANGES DURING ANY OTHER PART OF THE PROCEDURE? WERE THERE ANY UNTOWARD OR UNEXPECTED EVENTS DURING THE PROCEDURE? IF THERE WERE ANY UNTOWARD OR UNEXPECTED EVENTS, EXPLAIN WHAT WAS DONE TO
CORRECT THEM OR WHAT ADDITIONAL PROCEDURES WERE INITIATED AS A RESULT, INCLUDING
HEROIC ATTEMPTS AT RESUSCITATION (IF RESPIRATORY OR CARDIAC ARREST, DURATION): WHAT TIME WAS THE PROCEDURE TERMINATED? DID THE SUBJECT LEAVE THE OPERATING ROOM IN A STABLE CONDITION? RECOVERY DID THE DECEDENT ARRIVE AT THE RECOVERY ROOM IN A STABLE CONDITION? WERE ANY ADDITIONAL PROCEDURES PERFORMED ON THE DECEDENT WHILE IN RECOVERY?