More examples in Healthcare/Medical Examination Reports
Medical Examination for a Drowning Example
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DROWNING NAME OF DECEDENT: This form is to be completed in addition to the ROD form in these guidelines DECEDENT HOW LONG WAS THE DECEDENT MISSING? IF KNOWN, HOW LONG WAS THE DECEDENT SUBMERGED? DID THE DECEDENT ENTER THE WATER VOLUNTARILY OR INVOLUNTARILY (EXPLAIN)? DECEDENT WAS: SWIMMING WADING RESCUE ATTEMPT SCUBA DIVING UNKNOWN FELL FROM: FLOOD THROWN OTHER : HOW FAR FROM THE POINT OF ENTRY WAS THE BODY FOUND? IF BODY WAS REMOVED BY OTHER THAN SWIMMERS, WHAT WAS USED? GRAPPLE OTHER: DESCRIBE DECEDENT'S SWIMMING ABILITY: NONSWIMMER ADEQUATE GOOD EXPERT UNKNOWN HOW DID DECEDENT GET TO THIS AREA? IF VEHICLE WAS USED, HAS VEHICLE BEEN CHECKED? DID DECEDENT EAT OR DRINK ANYTHING PRIOR TO GOING INTO WATER? WAS THE DECEDENT PLAYING - (IF YES, WHAT WAS THE GAME AND WHAT WERE THE GAME
PIECES, IF ANY, I.E., BATS, BALLS, ETC.) WAS THE DECEDENT STRUCK BY ANY OBJECTS BEING USED IN THE GAME? GENERAL QUESTIONS FOR ALL DROWNINGS OTHER INDIVIDUALS PRESENT AT THE TIME OF THE DROWNING & THEIR RELATIONSHIP TO THE
DECEDENT? POND/LAKE STREAM RIVER FLOODWATER ARROYO OTHER: IS THIS AREA USUALLY USED FOR SWIMMING? ACCESS WAS: FENCED IN OPEN TO ANYONE PUBLIC PRIVATE IF FENCED, DID FENCE HAVE A GATE: NO YES - LOCKED UNLOCKED HOW HIGH WAS THE FENCE: THE GATE: IF WOODEN FENCE, MEASURE SPACE BETWEEN WOODEN SLATS: IS IT POSSIBLE TO SCALE, CLIMB THROUGH, OR UNDER THIS FENCE? TYPE OF BANK AT THE ENTRY POINT? CLIFF/OVERHANG WATER LEVEL OTHER: STEEP GRADUAL LEVEL CAN HISTORIAN DESCRIBE TEMPERATURE OF WATER WHEN DECEDENT WAS FOUND IN THE
P/T/S? ANY INDICATION THAT THE DECEDENT STRUCK ANY PORTION OF THE P/T/S OR THE DIVING
BOARD, OR THE BOTTOM? ANY ELECTRICAL APPLIANCES NEAR THE P/T/S, AND IF SO, DESCRIBE: DESCRIBE THE DRAINAGE SYSTEM AND INDICATE IF THE WATER DRAINED OUT: ANY INDICATION THE DECEDENT WAS SUCKED INTO OR ONTO THE DRAINAGE SYSTEM? BOATING/FISHING BRAND NAME OF BOAT: DID THE BOAT HAVE ANY KNOWN DEFECTS? DID BOAT HAVE SAFETY GEAR? DESCRIBE HOW DECEDENT FELL, JUMPED, OR WAS THROWN FROM BOAT? WAS THE DECEDENT WEARING SAFETY GEAR (DESCRIBE INCLUDING BRAND NAMES)? NAME OF INVESTIGATOR DMI# TYPE OF BOTTOM? MUD SAND GRAVEL BOULDERS UNKNOWN TYPE OF WATER? MUDDY CLEAR FRESH OTHER: MOVING WATER STILL WATER WATER MOVEMENT: DIRECTION FM TO APPROX. SPEED: IS THIS AREA KNOWN FOR: UNDERWATER HOLES UNDERCURRENTS SHIFTING BOTTOM OTHER: IS THIS AREA KNOWN FOR UNDERWATER OBSTRUCTIONS? IF PRIVATE, WAS DECEDENT ALLOWED TO BE THERE? IF PUBLIC, WAS DEATH DURING OPERATIONAL HOURS? IS/WAS A LIFEGUARD PRESENT AT THE TIME OF THE DROWNING? NO IF YES, ARE DETAILS OF THE DROWNING CONSISTENT WITH OTHER OBSERVERS? WERE ALCOHOLIC BEVERAGES OR FOOD BEING SERVED OR SOLD ON THE PREMISES? IF SAFETY DEVICES WERE INSTALLED OR WARNING SIGNS POSTED, DESCRIBE: WAS THERE ANYTHING UNUSUAL/OUT OF THE ORDINARY ABOUT THE WATER THAT SHOULD BE
NOTED? WHAT IS THE TEMPERATURE OF THE WATER AND HOW IS IT MEASURED? IS THIS AREA KNOWN FOR PRIOR DROWNINGS? MAXIMUM DEPTH AT ENTRY POINT: MIDWAY: WHERE BODY FOUND: POOL/TUB/SAUNA BRAND NAME OF POOL, TUB OR SAUNA: WAS P/T/S KNOWN TO BE DEFECTIVE IN ANY WAY? NO IF YES, EXPLAIN: WAS DECEDENT IN P/T/S WHEN FOUND? IF YES, HOW IS BODY POSITIONED? IF NO, WHERE IS BODY IN RELATION TO THE P/T/S? IN WHAT POSITION, AND WHAT IS HISTORY
BEHIND REMOVAL? IS WATER STILL IN P/T/S? YES IF NO, CAN FIRST RESPONDER INDICATE IF FACE OR HEAD OF THE DECEDENT WAS UNDER WATER? CAN FIRST RESPONDER DESCRIBE HOW DEEP THE WATER WAS WHEN THE DECEDENT WAS
FOUND IN THE P/T/S?
PIECES, IF ANY, I.E., BATS, BALLS, ETC.) WAS THE DECEDENT STRUCK BY ANY OBJECTS BEING USED IN THE GAME? GENERAL QUESTIONS FOR ALL DROWNINGS OTHER INDIVIDUALS PRESENT AT THE TIME OF THE DROWNING & THEIR RELATIONSHIP TO THE
DECEDENT? POND/LAKE STREAM RIVER FLOODWATER ARROYO OTHER: IS THIS AREA USUALLY USED FOR SWIMMING? ACCESS WAS: FENCED IN OPEN TO ANYONE PUBLIC PRIVATE IF FENCED, DID FENCE HAVE A GATE: NO YES - LOCKED UNLOCKED HOW HIGH WAS THE FENCE: THE GATE: IF WOODEN FENCE, MEASURE SPACE BETWEEN WOODEN SLATS: IS IT POSSIBLE TO SCALE, CLIMB THROUGH, OR UNDER THIS FENCE? TYPE OF BANK AT THE ENTRY POINT? CLIFF/OVERHANG WATER LEVEL OTHER: STEEP GRADUAL LEVEL CAN HISTORIAN DESCRIBE TEMPERATURE OF WATER WHEN DECEDENT WAS FOUND IN THE
P/T/S? ANY INDICATION THAT THE DECEDENT STRUCK ANY PORTION OF THE P/T/S OR THE DIVING
BOARD, OR THE BOTTOM? ANY ELECTRICAL APPLIANCES NEAR THE P/T/S, AND IF SO, DESCRIBE: DESCRIBE THE DRAINAGE SYSTEM AND INDICATE IF THE WATER DRAINED OUT: ANY INDICATION THE DECEDENT WAS SUCKED INTO OR ONTO THE DRAINAGE SYSTEM? BOATING/FISHING BRAND NAME OF BOAT: DID THE BOAT HAVE ANY KNOWN DEFECTS? DID BOAT HAVE SAFETY GEAR? DESCRIBE HOW DECEDENT FELL, JUMPED, OR WAS THROWN FROM BOAT? WAS THE DECEDENT WEARING SAFETY GEAR (DESCRIBE INCLUDING BRAND NAMES)? NAME OF INVESTIGATOR DMI# TYPE OF BOTTOM? MUD SAND GRAVEL BOULDERS UNKNOWN TYPE OF WATER? MUDDY CLEAR FRESH OTHER: MOVING WATER STILL WATER WATER MOVEMENT: DIRECTION FM TO APPROX. SPEED: IS THIS AREA KNOWN FOR: UNDERWATER HOLES UNDERCURRENTS SHIFTING BOTTOM OTHER: IS THIS AREA KNOWN FOR UNDERWATER OBSTRUCTIONS? IF PRIVATE, WAS DECEDENT ALLOWED TO BE THERE? IF PUBLIC, WAS DEATH DURING OPERATIONAL HOURS? IS/WAS A LIFEGUARD PRESENT AT THE TIME OF THE DROWNING? NO IF YES, ARE DETAILS OF THE DROWNING CONSISTENT WITH OTHER OBSERVERS? WERE ALCOHOLIC BEVERAGES OR FOOD BEING SERVED OR SOLD ON THE PREMISES? IF SAFETY DEVICES WERE INSTALLED OR WARNING SIGNS POSTED, DESCRIBE: WAS THERE ANYTHING UNUSUAL/OUT OF THE ORDINARY ABOUT THE WATER THAT SHOULD BE
NOTED? WHAT IS THE TEMPERATURE OF THE WATER AND HOW IS IT MEASURED? IS THIS AREA KNOWN FOR PRIOR DROWNINGS? MAXIMUM DEPTH AT ENTRY POINT: MIDWAY: WHERE BODY FOUND: POOL/TUB/SAUNA BRAND NAME OF POOL, TUB OR SAUNA: WAS P/T/S KNOWN TO BE DEFECTIVE IN ANY WAY? NO IF YES, EXPLAIN: WAS DECEDENT IN P/T/S WHEN FOUND? IF YES, HOW IS BODY POSITIONED? IF NO, WHERE IS BODY IN RELATION TO THE P/T/S? IN WHAT POSITION, AND WHAT IS HISTORY
BEHIND REMOVAL? IS WATER STILL IN P/T/S? YES IF NO, CAN FIRST RESPONDER INDICATE IF FACE OR HEAD OF THE DECEDENT WAS UNDER WATER? CAN FIRST RESPONDER DESCRIBE HOW DEEP THE WATER WAS WHEN THE DECEDENT WAS
FOUND IN THE P/T/S?