Get Dch Contrast Material Extravasation Form - Dearborn County Hospital

This guide provides a clear, step-by-step process for users to complete the Dch Contrast Material Extravasation Form online. By following these instructions, you will be able to effectively fill out the form with the necessary information.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the Dch Contrast Material Extravasation Form in an editable format.
2. Begin by entering the patient’s name in the designated field, ensuring that it matches the patient's official records.
3. Input the patient number, which is a unique identifier for the individual in the hospital's system.
4. Fill in the date when the form is being completed.
5. Enter the patient’s date of birth to confirm their identity.
6. Document the time of filling out the form.
7. Input the patient's age, as it may be pertinent for treatment details.
8. Provide a phone number for the patient, ensuring it is correct for any follow-up communications.
9. Include the referring physician's contact number.
10. Indicate whether the physician has been notified of the extravasation by marking 'Yes' or 'No'.
11. Enter the name of the referring physician to establish responsibility for follow-up care.
12. Record the amount of contrast material that has been extravasated.
13. Specify the type of contrast material that was used.
14. Identify the physician currently treating the patient, along with their signature if applicable.
15. In the comments section, provide any relevant notes regarding the incident.
16. Mark the initial treatments that have been provided for the extravasation, such as elevation and warm compress.
17. Indicate whether a copy of discharge instructions for treatment is available by marking 'Yes' or 'No'.
18. Document the observation time following the treatment.
19. For the initial patient assessment, note any observed symptoms such as pain, blistering, or changes in skin color.
20. In the comments/patient's instructions section, provide detailed instructions or comments relevant to the patient’s care.
21. Sign and date the form to confirm that the information provided is accurate.
22. For patient follow-up assessments, repeat the symptom checks and note any changes since the initial assessment.
23. Complete the follow-up comments/patient's instructions section similarly to the initial assessment.
24. Ensure signatures and dates are included for the follow-up assessment, completing the form.
25. After completing the form, you can save your changes, download the document, print it, or share it as needed.

Start filling out the Dch Contrast Material Extravasation Form online today to ensure accurate documentation.