The SDMC 220 B form is a vital document designed for the Surrogate Decision-Making Committee (SDMC), serving a critical role in the supplemental medical proceeding for reviewing the necessity of surrogate decision-making on a patient's behalf. This comprehensive form, revised in July 2013, mandates a detailed enumeration of the patient's current medications, including dosages and mode of intake, in addition to any drugs requiring frequent blood level monitoring. It calls for disclosing any known allergies, the details of the latest annual physical examination along with abnormal findings, most recent EKG, Chest X-ray, and laboratory tests, securing a thorough assessment of the patient's health status. Intriguingly, it probes into the patient's past experiences with major illnesses, surgeries, hospitalizations in the preceding year, any cardiac or pulmonary conditions, other known physical conditions, and specifically inquires about the patient's history with general anesthesia, emphasizing on any adverse reactions encountered. Another unique aspect of the form is its requirement for the patient's presence at the hearing, as mandated by MHL Article 80, unless a medical condition prevents it, adding a layer of complexity to the decision-making process. Furthermore, it inquires about the scheduling of the requested procedures, previous reviews by the SDMC, and if the patient has been transferred to another healthcare facility, demanding detailed contact information. This exhaustive form underscores the thoroughness required in surrogate decision-making processes, reflecting the committee's commitment to making well-informed decisions that align with the best interests of those unable to make such decisions for themselves.
| Question | Answer |
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| Form Name | Sdmc Form 220 B |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | sdmc form 220 b, Consults, MHL, sdmc forms download |
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**DO NOT STAPLE FORMS** |
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SDMC FORM |
SURROGATE |
SUPPLEMENTAL MEDICAL |
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PROCEEDING FOR THE REVIEW OF THE NEED FOR |
INFORMATION |
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SURROGATE |
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Declaration # (SDMC Use Only) |
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(Patient’s Name) |
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ALL QUESTIONS MUST BE ANSWERED TO PREVENT A DELAY IN PROCESSING THE CASE
1a. Current medications, dosages, frequency and mode of intake:
1b. List any drugs requiring frequent blood level monitoring. (Include copy)
2.Any known allergies:
3. Annual physical examination:(Must include copy)
(Date)
Abnormal findings:
4.Most recent EKG:
5.Most recent Chest
6.Most recent laboratory tests:
(Date)
(Date)
(Date)
(Include copy, if available) (Include copy, if available) (Include copy, if available)
7. |
Has there been a second opinion? If so what type? |
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Best Interest |
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(REV. 07/2013) |
**DO NOT STAPLE FORMS** |
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SDMC FORM |
8.List any cardiac or pulmonary condition(s):
9.List any major illness, surgery and/or hospitalizations in the last year:
10.List any other known physical conditions:
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Has this patient had general anesthesia before? |
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Yes |
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No |
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Unknown |
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Date of most recent general anesthesia: |
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Any history of adverse reactions to general anesthesia? |
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Yes |
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No |
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Unknown |
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*IV sedation and MAC are not considered general anesthesia for SDMC cases.
If yes, describe:
12.MHL Article 80 requires the patient to be present at the hearing. Is there any medical condition that
would prevent the patient from attending the hearing? |
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Yes |
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No |
If yes, explain:
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**DO NOT STAPLE FORMS** |
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SDMC FORM |
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13. |
Is the requested procedure(s) scheduled? |
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Yes |
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No |
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If yes, date: |
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If no, when is the anticipated scheduled date? |
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Has the patient been reviewed by SDMC previously? |
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Yes |
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No |
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Unknown |
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If yes, answer the following (if known): |
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a.Date most recent SDMC approved procedure performed:
b.Procedure(s) previously requested:
c.Results of procedure(s):
15.If the patient has been transferred to a healthcare facility other than their residence, please provide the following information:
Facility Name:
Facility Address:
Facility Contact Person: Name:
Contact’s Phone #: ( ) |
Patient’s Room #: |
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16. The above information and statements are to the best of my knowledge truthful and complete.
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Print Name Clearly |
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Signature |
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Title |
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Date |
Work Phone: ( |
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Work Cell: ( |
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Work Fax: ( |
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PLEASE REMEMBER TO ATTACH:
Consults, progress notes, annual physical exam, results of diagnostic tests and other documentation related to the proposed major medical treatment(s) being requested.