Form 1b Imminent-Eligible Death Doc

Local Death Notification ?

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DonorNet ID: ABC123

Doe, Jane

Summary

Registration

Status

PROVIDER INFORMATION

?

OPO: *

123456 - ABCD - ABCD Organ

Donor hospital:*

123456 - DCBA - DCBA Hospital

Has consent been obtained? *

Yes

Requested by: *

Doe, Jane (1118)

Time zone: *

Central

Is Daylight Savings Time observed? * Yes
?

STATUS DETERMINATION

Eligibility status:

Unknown

Imminent neurological death:

Unknown

Ventilator support?:

Yes

No

Severe neurological Injury?:

Yes

No

GCS known?:

Yes

No

Yes

No

Absence of brain stem
reflexes?:
Which reflexes are
absent?

Corneal reflex

Cough reflex

Doll’s eyes reflex

Gag reflex

Pupillary reaction
Response to painful stimuli

Response to iced caloric
Spontaneous breathing

Deteriorated to cardiac death?:

Yes

No

Legally declared brain dead?:

Yes

No

Exclusions:
Exclusion

Category

Agranulocytosis:

General

Aplastic anemia:

General

Aspergillus (active):

Fungal

Candidemia (active) or yeast
infection (invasive):
Coccidioides (active):

Fungal
Fungal

CMV (active):

Viral

Creutzfeldt-Jacob Disease

Prion

Cryptococcus (active):

Fungal

Current malignant neoplams:
EBNA:

General

EBV VCA IgG:
EBV VCA IgM:

Viral
Viral

Encephalitis (active):

Viral
Bacterial

Encephalitis (active):

Fungal

Encephalitis (active):

Parasitic

Encephalitis (active):

Viral

Gangrenous bowel:

Bacterial

HBsAg (reactive):
Herpes simplex (active):

Viral
Viral

Histoplasma (active):

Fungal

History of melanoma:

General

Hodgkins’ disease:

Check all
that apply

General
Viral

HTLV I/II:

Viral

Immaturity (extreme):

General

Intra-abdominal sepsis:

Bacterial

Leishmania (active):
Leprosy:

Parasitic

Leukemia:

General

Lymphoma:

General

Malaria/Plasmodium (active):

Parasitic

Meningitis (active):

Bacterial

Meningitis (active):

Fungal

Meningitis (active):

Parasitic

Bacterial

Meningitis (active):

Viral

Myeloma (multiple):
Multi-system organ failure:

General
General

Perforated bowel:
Pneumonia (active):

Bacterial
Viral

Previous malignant neoplasms with
current evident metastatic disease:

General

Rabies:

Viral

Retroviral infections:

Viral

SARS:

Viral

Strongyloides (active):

Parasitic

Trypanosoma cruzi (active):

Parasitic

Tuberculosis:

Bacterial
Viral

Varicella zoster (active):
West nile virus infection:

Viral

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High-level workflow
Imminent and Eligible Death Data Collection Project

Death Notification

Eligible
Consented

Imminent
Consented

Other
Consented

Eligible
NonConsenting

Imminent Death
version of new
form (Form A)

Imminent
NonConsenting

Eligible Death
version of new
form (Form C)

End

Imminent Death
version of new
form (Form A)

End

Was one organ
recovered for
transplantation?

No

Short version of
the DDR (Form B)

Yes

DDR

End

Additional data does not
need to be collected on nonconsenting individuals who
do not meet the definition of
eligible or imminent death.

Other
NonConsenting

Death Notification Registration - Version A – Imminent Neurological Death

Local Death Notification

?

Related Links
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View contact log
Attachment view log

Doe, Jane

Summary

DonorNet ID: ABC123

Registration

STATUS: INCOMPLETE
PROVIDER INFORMATION
OPO:*

123456 - ABCD - ABCD Organ Center

Donor hospital:*

123456 - ABCD Organ Center

Date and time of pronouncement
of death: *

Date:

How did you learn of this case?:*

Time: (military time)

Donor hospital notification

Retrospective review

Date of hospital notification: *
Has consent been obtained
for organ donation?: *

No

Was consent requested?: *

Yes

No

Reason consent not
requested: *
Requested by: *
DEMOGRAPHICS
Last name:*
Doe

First name: *
Jane

ABO:

O

A

B

A1

A1B

A2

A2B

DOB: *

Age: *

05/27/1976

29 Years

Eligibility status: *
Eligible

Imminent neurological death: *
No

Cause of death: *
Specify: *

Gender: *
Male

Female

Other Specify
Specify Here

Mechanism of death: *

Blunt Injury

Circumstances of death: *

Child Abuse

Ethnicity/race:*

AB

Cuban

PROCUREMENT AND CONSENT
Was intent to be a donor documented?: *
Mechanisms that apply: *

yes

no

unknown

Driver’s license

Donor card

Donor registry

Durable power of attorney/healthcare proxy
Other, Specify
Tests that confirmed neurological death: *

Angiography
Other, Specify

*
Specify:
EEG

Flow study

Specify:*

Validate

Save

Add

Death Notification Registration - Version B – Abbreviated DDR

Local Death Notification

?

Related Links
Return to search
Return to list
View contact log
Attachment view log

Doe, Jane

Summary

DonorNet ID: ABC123

Registration

STATUS: INCOMPLETE
PROVIDER INFORMATION
OPO:*

123456 - ABCD - ABCD Organ Center

Donor hospital:*
Date and time of pronouncement
of death: *

123456 - ABCD Organ Center
Time: (military time)

Date:

How did you learn of this case?:*

Donor hospital notification

Retrospective review

Date of hospital notification: *
Has consent been obtained
for organ donation?: *

Yes

Requested by: *
DEMOGRAPHICS
Last name:*
Doe

First name: *
Jane

ABO: *

O

A

B

AB

A1

A1B

A2

A2B

DOB: *

Age: *

05/27/1976

29 Years

Eligibility status: *
Eligible

Imminent neurological death: *
No

Cause of death: *
Specify: *

Gender: *
Male

Other Specify
Specify Here

Mechanism of death: *

Blunt Injury

Circumstances of death: *

Child Abuse

Ethnicity/race:*

Female

Cuban

PROCUREMENT AND CONSENT
Medical Examiner/Coroner accepted case?: *
Medical Examiner/Coroner’s decision: *
Was intent to be a donor documented?: *
Mechanisms that apply: *

yes

no

consented

refused consent

yes

no

unknown

Driver’s license

Donor card

Donor registry

Durable power of attorney/healthcare proxy
Other, Specify
Consent based only on
documentation?: *
Did the patient express to family
or others the intent to be a donor?:*
Date and time consent obtained
for first organ:*

*
Specify:

yes

no

unknown

yes

no

unknown

Date:

Time: (military time)

CLINICAL INFORMATION
Terminal lab data:
Serum Creatinine:*

mg/dl

ST=

BUN:*

mg/dl

ST=

SGOT/AST:*

u/L

ST=

SGPT/ALT:*

u/L

ST=

LIFESTYLE FACTORS
History of hypertension:*

YES, 6-10 YEARS

If yes, method of control:*
Diet:

yes

no

unknown

Diuretics:

yes

no

unknown

Other hypertensive medication:

yes

no

unknown

Validate

Save

Death Notification Registration - Version C – Non-Consenting Eligible Death

Local Death Notification

?

Related Links
Return to search
Return to list
View contact log
Attachment view log

Doe, Jane

Summary

DonorNet ID: ABC123

Registration

STATUS: INCOMPLETE

PROVIDER INFORMATION
OPO:*

123456 - ABCD - ABCD Organ Center

Donor hospital:*

123456 - ABCD Organ Center

Date and time of pronouncement
of death: *

Date:

How did you learn of this case?:*

Time: (military time)

Donor hospital notification

Retrospective review

Date of hospital notification: *
Has consent been obtained
for organ donation?: *

No

Was consent requested?: *

Yes

No

Reason consent not
requested: *
Requested by: *
DEMOGRAPHICS
Last name:*
Doe

First name: *
Jane

ABO:

O

A

B

A1

A1B

A2

A2B

DOB: *

Age: *

05/27/1976

29 Years

Eligibility status: *
Eligible

Imminent neurological death: *
No

Cause of death: *
Specify: *

Gender: *
Male

Female

Other Specify
Specify Here

Mechanism of death: *

Blunt Injury

Circumstances of death: *

Child Abuse

Ethnicity/race:*

AB

Cuban

PROCUREMENT AND CONSENT
Medical Examiner/Coroner accepted case?: *
Medical Examiner/Coroner’s decision: *
Was intent to be a donor documented?: *
Mechanisms that apply: *

yes

no

consented

refused consent

yes

no

unknown

Driver’s license

Donor card

Donor registry

Durable power of attorney/healthcare proxy
Other, Specify
Consent based only on
documentation?: *

yes

*
Specify:
no

unknown
Validate

Save