Form Dhec 3485 PDF Details

When it comes to ensuring seamless patient care during transfers between medical facilities, the Dhec 3485 form plays a pivotal role. Created by the South Carolina Department of Health and Environmental Control, specifically under the Division of EMS and Trauma, this detailed document serves as a comprehensive interfacility transport form encompassing two critical parts: a Drug Report (Part A) and a Device Report (Part B). Each section is meticulously designed to capture essential information, including patient identifiers, physician details, patient diagnosis, vital signs, administered IV fluids, medications, and any pertinent comments or additional orders from the sending physician. The form also requires information about any interfacility invasive or implanted devices being used during transport, ensuring that the receiving facility is fully informed of the patient's condition and any specialized care they are receiving. The precision of this form in documenting both pharmacological and mechanical aspects of a patient's in-transfer care highlights its importance in bridging the gap between sending and receiving facilities, ultimately facilitating a smoother transition and continuity of care for the patient.

QuestionAnswer
Form NameForm Dhec 3485
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesems administrative forms pdf, 2010, Suprapubic, dhec forms interfacility drop form

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SCDHEC – DIVISION OF EMS AND TRAUMA

INTERFACILITY TRANSPORT FORM

PART A - DRUG REPORT

Patient Care Form #: ________________________________________________

Patient Name: ______________________________________________________ DOB: ________________________

LAST

FIRST

 

Referring Physician: _______________________________

Transferring Facility: _____________________________

Accepting Physician: ______________________________

Receiving Facility: _______________________________

*****************************************************************************************************************************************

Instructions: Part A (Drug Report) and Part B (Device Report) must be completed by and signed by the sending physician.

*****************************************************************************************************************************************

DIAGNOSIS: (1)

 

LAST VITAL SIGNS: __________________________

 

(2)

 

 

 

 

 

 

 

 

 

(3)

 

 

 

 

 

 

 

 

 

IV Fluids:

 

 

Rate:

 

 

Medications:

 

 

 

 

 

 

Dosage / Rate/Concentration:

 

 

 

 

 

 

Comments/Additional Orders:

 

 

 

 

 

 

IV Fluids:

 

 

Rate:

 

 

Medications:

 

 

 

 

 

 

Dosage / Rate/Concentration:

 

 

 

 

 

 

Comments/Additional Orders:

 

 

 

 

 

 

IV Fluids:

 

 

Rate:

 

 

Medications:

 

 

 

 

 

 

Dosage / Rate/Concentration:

 

 

 

 

 

 

Comments/Additional Orders:

 

 

 

 

 

 

PLEASE CHECK THE INTERFACILITY DEVICES BEING USED IN THIS TRANSPORT ON

THE BACK PAGE OF THIS FORM.

This report was given by (physician):

 

Date:

 

 

(None of the drugs being sent with this patient are part of an experimental program.)

 

This report was accepted by (EMT-P signature):

 

 

 

Date:

 

 

EMS Service must retain a copy of this form for their records.

If any problems are experienced en route, the EMT-P must contact on-line medical control.

-over-

DHEC 3485 (11/2010)

SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL

 

 

 

PART B - DEVICE REPORT

Patient Care Form #:

 

 

 

 

 

 

 

 

Patient Name:

 

 

 

 

 

 

 

DOB: _________________________

 

LAST

 

 

FIRST

Referring Physician:

 

 

 

Transferring Facility:

 

 

Accepting Physician:

 

 

 

Receiving Facility:

 

 

*****************************************************************************************************************************************

Instructions: Part A (Drug Report) and Part B (Device Report) must be completed by and signed by the sending physician.

*****************************************************************************************************************************************

INTERFACILITY INVASIVE/IMPLANTED DEVICES USED IN THIS TRANSPORT

Check all devices being used:

___

Automatic Internal Cardiac Deibrillator (AICD)

___

Arterial Lines, Arterial Sheathes

___

Tube Thoracostomy/Chest Tube

___

Percutaneously Placed Central Venous Catheters (does not include Swan-Ganz catheters)

___

Peritoneal Dialysis Catheters

___

Epidural Catheters

___

Urethral/Suprapubic Catheter

___

Implantable Central Venous Catheters

___

Nasogastric/Orogastric Tubes

___

Surgically Placed Gastrointestinal Tubes

___

Percutaneous Drainage Tubes

___

Completely Implantable Venous Access Port

___

Surgical Drains

Comments/Additional Orders:

DHEC 3485 (11/2010)

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