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.
Question | Answer |
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Form Name | Form Dhec 3485 |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | ems administrative forms pdf, 2010, Suprapubic, dhec forms interfacility drop form |
SCDHEC – DIVISION OF EMS AND TRAUMA
INTERFACILITY TRANSPORT FORM
PART A - DRUG REPORT
Patient Care Form #: ________________________________________________
Patient Name: ______________________________________________________ DOB: ________________________
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Referring Physician: _______________________________ |
Transferring Facility: _____________________________ |
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Accepting Physician: ______________________________ |
Receiving Facility: _______________________________ |
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Instructions: Part A (Drug Report) and Part B (Device Report) must be completed by and signed by the sending physician.
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DIAGNOSIS: (1) |
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LAST VITAL SIGNS: __________________________ |
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(2) |
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(3) |
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IV Fluids: |
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Medications: |
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Dosage / Rate/Concentration: |
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Comments/Additional Orders: |
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IV Fluids: |
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Comments/Additional Orders: |
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PLEASE CHECK THE INTERFACILITY DEVICES BEING USED IN THIS TRANSPORT ON
THE BACK PAGE OF THIS FORM.
This report was given by (physician): |
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(None of the drugs being sent with this patient are part of an experimental program.) |
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This report was accepted by |
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EMS Service must retain a copy of this form for their records.
If any problems are experienced en route, the
DHEC 3485 (11/2010) |
SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL |
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PART B - DEVICE REPORT |
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Patient Care Form #: |
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Patient Name: |
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DOB: _________________________ |
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Referring Physician: |
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Transferring Facility: |
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Accepting Physician: |
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Receiving Facility: |
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Instructions: Part A (Drug Report) and Part B (Device Report) must be completed by and signed by the sending physician.
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INTERFACILITY INVASIVE/IMPLANTED DEVICES USED IN THIS TRANSPORT
Check all devices being used:
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Automatic Internal Cardiac Deibrillator (AICD) |
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Arterial Lines, Arterial Sheathes |
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Tube Thoracostomy/Chest Tube |
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Percutaneously Placed Central Venous Catheters (does not include |
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Peritoneal Dialysis Catheters |
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Epidural Catheters |
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Urethral/Suprapubic Catheter |
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Implantable Central Venous Catheters |
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Nasogastric/Orogastric Tubes |
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Surgically Placed Gastrointestinal Tubes |
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Percutaneous Drainage Tubes |
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Completely Implantable Venous Access Port |
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Surgical Drains |
Comments/Additional Orders:
DHEC 3485 (11/2010)