Form Dhec 3485 PDF Details

Form Dhec 3485 is a document used to report the death of a person. This form must be completed within five days of the death and filed with the South Carolina Department of Health and Environmental Control. The information on this form can be used to help track public health trends and investigate potential causes of death. Completing this form accurately is critical, so please read the instructions carefully.

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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