Free Wisconsin Organ and Tissue Recovery and Assessment, DPH 43023 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 43023 (08/06)

STATE OF WISCONSIN Page 1 of 6

WISCONSIN ORGAN AND TISSUE RECOVERY AND ASSESSMENT
Pursuant to Wisconsin Statute Section 157.06 (4m) (e), the following information is to be provided to the Coroner or Medical Examiner's Office at the time of initial request to recover anatomical gifts. Decedent's Name Age Race Sex

Medical Record No.

Type of Donor Brain death Cardiac death

Date and Time of Death

Hospital Death Scene Death

Hospital Name__________________________

Time last known alive if time of death is uncertain:

Briefly describe events leading to death:

Name of Coroner or Medical Examiner Contacted

County of Origin

Date and Time

Name of Investigator (if known)

Date and Time

Coroner or Medical Examiner Case Number

Family member contacted for donation?

Yes

No

Telephone No.

Relationship to donor

Address

ORGANS REQUESTED Heart / Pericardium Lungs TISSUE REQUESTED Upper arm bones Heart for valves; descending thoracic aorta; pericardium Bones of the leg and pelvis Blood vessels (femoral, saphenous, aortic iliac graft) Connective Tissue Eyes / Whole Globe Vertebral bodies Corneas Skin Other: Intestine Lymph Nodes Kidneys (with adrenals) Pancreas Liver Spleen

SIGNATURE ­ Person Completing Form

Print Name and Title

Date Signed

Wisconsin Organ and Tissue Recovery / Assessment DPH 43023 (08/06) Donor Name Medical Record No.

Page 2 of 6

MEDICAL RECORDS REVIEW
Review of Medical Records to ensure documentation of the following External injuries (including retinal hemorrhage)

If patterned injuries (including bite marks) are present, where on the body are they located?

Internal Injuries Fractures

PHYSICAL FINDINGS
CT scan or MRI of the head? Fresh fractures of long bones, clavicles or ribs? (Particular attention to be paid to metaphysical long bone, clavicle and rib fractures) Retinal hemorrhage or other eye injury? Physical Assessment Key 1. Tattoos 2. Non-therapeutic needle marks 3. Lesions 4. Scars 5. Deformities 6. I.V. Sites or arterial line 7. Contusions 8 Abrasions 9. Surgical Incisions 10. Eye injurries (e.g. Petechiae) 11. Other (List):

SIGNATURE ­ Person Completing Form

Print Name and Title

Date Signed

Wisconsin Organ and Tissue Recovery / Assessment DPH 43023 (08/06) Donor Name Medical Record No.

Page 3 of 6

Tests used to determine suitability of organs for purposes of transplantation (Please check appropriate boxes--exact results not necessary, only whether test was done or not) HEART LIVER KIDNEYS PANCREAS LUNGS INTESTINES ECG Liver Function Tests BUN Amylase CXR Liver Function Tests Echocardiogram Coagulation Studies Serum Creatinine Serum Glucose ABG's Coagulation Studies CPK Other Urinalysis Lipase Sputum Gram Stain Other

BLOOD DRAWS Date and Time Admission Blood Anti-mortem Post-mortem Date and Time of Cardiac Asystole: Date and Time of Aorta Cross Clamp: Site Drawn by

MD / Technician Signature

Organization Name

Wisconsin Organ and Tissue Recovery / Assessment DPH 43023 (08/06) Donor Name Medical Record No.

Page 4 of 6

THORACIC CAVITY
RIGHT LUNG Operative procedure according to Recovery Center protocol Evaluation shows normal organ function (Serum Electrolytes, CBC, Chest X-Ray, Blood Gases, Gram Stain) Organ function appears abnormal (add comments): Organ function appears abnormal (add comments): LEFT LUNG

No gross pathology noted in organ Pathology noted in organ (add comments): Organ not recovered Additional findings:

No gross pathology noted in organ Pathology noted in organ (add comments): Organ not recovered Additional findings:

Surgeon Name

Surgeon Hospital

HEART AND PERICARDIUM Operative procedure according to Recovery Center protocol Evaluation shows normal organ functioning (Serum Electrolytes, CBC, ECG, Echocardiogram, Chest X-Ray. Blood Gases) Organ function appears abnormal (add comments) No gross pathology noted in organ Pathology noted in organ (add comments): Organ not recovered Additional findings:

Surgeon Name

Surgeon Hospital

Wisconsin Organ and Tissue Recovery / Assessment DPH 43023 (08/06) Donor Name Medical Record No.

Page 5 of 6

ABDOMINAL CAVITY
RIGHT KIDNEY AND ADRENAL Operative procedure according to Recovery Center protocol Evaluation shows normal organ functioning (Serum Electrolytes, CBC, BUN, Serum Creatinine, Urinalysis, Urine Output) Organ function appears abnormal (add comments): Organ function appears abnormal (add comments): LEFT KIDNEY AND ADRENAL

No gross pathology noted in organ Pathology noted in organ (add comments): Organ not recovered Additional findings:

No gross pathology noted in organ Pathology noted in organ (add comments): Organ not recovered Additional findings:

Surgeon Name

Surgeon Hospital

PANCREAS AND SPLEEN Operative procedures according to Recovery Center protocol Evaluation shows normal organ function (Serum Electrolytes; CBC, Amylase, Serum Glucose) Organ function appears abnormal (add comments): No gross pathology noted in organ Pathology noted in organ (add comments): Organ not recovered Additional findings:

Surgeon Name

Surgeon Hospital

Wisconsin Organ and Tissue Recovery / Assessment DPH 43023 (08/06) Donor Name Medical Record No.

Page 6 of 6

ABDOMINAL CAVITY (continued)
INTESTINE AND LYMPH NODES Operative procedure according to Recovery Center protocol Evaluation shows normal organ function (Serum Electrolytes, CBC, Coagulation Studies, Liver Function Tests) Organ function appears abnormal (add comments) No gross pathology noted in organ Pathology noted in organ (add comments): Organ not recovered Additional findings:

Surgeon Name

Surgeon Hospital

LIVER Operative procedure according to Recovery Center protocol Evaluation shows normal organ function (Serum Electrolytes, CBC, Coagulation Studies, Liver Function Tests, Other _________________) Organ function appears abnormal (add comments) No gross pathology noted in organ Pathology noted in organ (add comments): Organ not recovered Additional findings:

Surgeon Name

Surgeon Hospital