Get Client / Patient Death Determination

The Client / Patient Death Determination form is a vital document mandated by Wisconsin state law to report certain client, patient, or resident deaths. Accurate completion is essential to ensure compliance and facilitate necessary investigations. This guide provides detailed instructions to help users confidently complete the form online.

Follow the steps to accurately complete the form.

1. Click ‘Get Form’ button to access the Client / Patient Death Determination form online. This action will provide you with the necessary template to fill out.
2. Begin by filling in the deceased individual's details in the 'Determination' section. Enter the name (last, first, middle initial), date of birth, sex, admission date, and ethnicity. Ensure all information is accurate and clearly filled out.
3. Indicate whether the death is reportable to the coroner or medical examiner by selecting 'Yes' or 'No'. This is a critical field as it may affect compliance requirements.
4. Provide the name of the agency or provider, including their certification or license number and address. This information links the report to the responsible entity.
5. Complete the emergency contact section with the name of the client emergency contact person, their relationship to the deceased, and their telephone number.
6. Fill in the 'To Whom Reported' section, including the name, title, and contact information of the individual receiving the report. Ensure this information is current to prevent delays in processing.
7. Document the date of death and the date reported. It is essential that these dates are completed accurately to comply with reporting timelines.
8. Answer the questions in sections A, B, and C regarding suicide, psychotropic medications, and physical restraints or seclusion. Select “Yes” or “No” as appropriate, ensuring that you provide accurate responses based on the deceased’s circumstances.
9. In the 'Reason for Reporting' section, name the individual involved in the case, and provide their title and contact number to allow for direct follow-up if necessary.
10. Finally, review all completed sections for accuracy before signing the form. Provide the signature of the person completing the form along with the date signed.
11. Once all sections are filled accurately, save any changes you made, download a copy for your records, or print the form if needed. Once finalized, ensure the form is submitted as required.

Get started today by filling out the Client / Patient Death Determination form online to ensure compliance and facilitate necessary reporting.