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Natural Death Worksheet Medical Examination Example
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Text in this example:
DOES THE PHYSICIAN HAVE ANY INFORMATION CONCERNING THE GENERAL CARE AND WELFARE OF THE DECEDENT? HAS PHYSICIAN AGREED, BASED ON THE DECEDENT'S MEDICAL RECORD AND OMI INVESTIGATION, TO SIGN THE DEATH CERTIFICATE, AND IF SO, HOW IS IT TO BE SIGNED OUT? IF PHYSICIAN IS UNCOMFORTABLE WITH SIGNING THE DEATH CERTIFICATE, IS THERE ANY
REASON BASED ON THE CHAIN OF EVENTS AND THE SCENE INVESTIGATION TO SUGGEST THAT
THIS IS OTHER THAN A DEATH DUE TO NATURAL CAUSES? WHAT CIRCUMSTANCES SUGGEST THAT THIS DEATH IS WITHOUT A DOUBT DUE TO NATURAL
CAUSES? BASED ON WHAT CRITERIA DID OMI ASSUME FULL JURISDICTION IN THIS DEATH (EXTERNAL OR AUTOPSY)? IS INFORMANT COMFORTABLE THAT AN AUTOPSY WILL NOT BE PERFORMED BY THE MEDICAL INVESTIGATOR IF THIS IS RULED TO BE A TERMINATED JURISDICTION CASE OR THAT AN EXTERNAL EXAMINATION ONLY IS TO BE PERFORMED? NAME OF INVESTIGATOR DMI# NATURAL DEATH WORKSHEET NAME OF DECEDENT: This form is to completed in addition to the ROD form in these guidelines NAME OF INFORMANT: RELATION SHIP TO THE DECEDENT: ADDRESS: TEL #: DOES THE DECEDENT LIVE ALONE? YES NO IF NO, WHO ELSE LIVES WITH THE DECEDENT? WHEN AND IN WHAT CONDITION WAS THE DECEDENT WHEN LAST SEEN ALIVE (INDICATE ANY
PROBLEMS, COMPLAINTS, RECENT TRAUMA, ETC.)? HOW DOES THE INFORMANT DESCRIBE THE DECEDENT'S HEALTH GENERALLY? DOES THE INFORMANT HAVE ANY RESERVATIONS THAT THIS IS A NATURAL DEATH? IS INFORMANT AWARE OF AND COMFORTABLE WITH MEDICAL TREATMENT RECEIVED? DOES INFORMANT HAVE ANY SPECIAL CONCERNS? THE PRIMARY CARE PHYSICIAN ARE ANY OTHER PHYSICIANS AWARE OF THIS PATIENT FOR NOTIFICATION PURPOSES - INDICATE NAME AND CONTACT NUMBER(S)? IF MEDICAL HISTORY HAS BEEN VERIFIED, HOW DOES PRIVATE PHYSICIAN DESCRIBE "TERMINAL STATUS" OF THE DECEDENT (IS THIS AN EXPECTED DEATH)? IF THIS IS AN UNEXPECTED BUT NOT UNEXPLAINABLE DEATH, DOES THE PRIVATE PHYSICIAN
HAVE ANY RESERVATIONS ABOUT THE POSSIBLE CAUSE OF DEATH?
REASON BASED ON THE CHAIN OF EVENTS AND THE SCENE INVESTIGATION TO SUGGEST THAT
THIS IS OTHER THAN A DEATH DUE TO NATURAL CAUSES? WHAT CIRCUMSTANCES SUGGEST THAT THIS DEATH IS WITHOUT A DOUBT DUE TO NATURAL
CAUSES? BASED ON WHAT CRITERIA DID OMI ASSUME FULL JURISDICTION IN THIS DEATH (EXTERNAL OR AUTOPSY)? IS INFORMANT COMFORTABLE THAT AN AUTOPSY WILL NOT BE PERFORMED BY THE MEDICAL INVESTIGATOR IF THIS IS RULED TO BE A TERMINATED JURISDICTION CASE OR THAT AN EXTERNAL EXAMINATION ONLY IS TO BE PERFORMED? NAME OF INVESTIGATOR DMI# NATURAL DEATH WORKSHEET NAME OF DECEDENT: This form is to completed in addition to the ROD form in these guidelines NAME OF INFORMANT: RELATION SHIP TO THE DECEDENT: ADDRESS: TEL #: DOES THE DECEDENT LIVE ALONE? YES NO IF NO, WHO ELSE LIVES WITH THE DECEDENT? WHEN AND IN WHAT CONDITION WAS THE DECEDENT WHEN LAST SEEN ALIVE (INDICATE ANY
PROBLEMS, COMPLAINTS, RECENT TRAUMA, ETC.)? HOW DOES THE INFORMANT DESCRIBE THE DECEDENT'S HEALTH GENERALLY? DOES THE INFORMANT HAVE ANY RESERVATIONS THAT THIS IS A NATURAL DEATH? IS INFORMANT AWARE OF AND COMFORTABLE WITH MEDICAL TREATMENT RECEIVED? DOES INFORMANT HAVE ANY SPECIAL CONCERNS? THE PRIMARY CARE PHYSICIAN ARE ANY OTHER PHYSICIANS AWARE OF THIS PATIENT FOR NOTIFICATION PURPOSES - INDICATE NAME AND CONTACT NUMBER(S)? IF MEDICAL HISTORY HAS BEEN VERIFIED, HOW DOES PRIVATE PHYSICIAN DESCRIBE "TERMINAL STATUS" OF THE DECEDENT (IS THIS AN EXPECTED DEATH)? IF THIS IS AN UNEXPECTED BUT NOT UNEXPLAINABLE DEATH, DOES THE PRIVATE PHYSICIAN
HAVE ANY RESERVATIONS ABOUT THE POSSIBLE CAUSE OF DEATH?