Get Samsha Otp Mortality Report Form

Completing the Samsha Otp Mortality Report Form online is an essential step for facilitating the review of patients who have passed while enrolled in Opioid Treatment Programs. This guide provides clear and supportive instructions to ensure that every user can navigate the form with ease and accuracy.

Follow the steps to complete the Samsha Otp Mortality Report Form effectively.

1. Press the ‘Get Form’ button to obtain the report form and access it in your editing interface.
2. Fill in the date of the report in the designated field, using the format mm/dd/yyyy.
3. Indicate if this is a follow-up report by selecting 'Yes' or 'No' as required.
4. In the background information section, enter the patient’s OTP ID number and program OTP number, ensuring they match the SAMHSA ID.
5. Provide the patient’s date of birth and ZIP code of residence.
6. Select the patient’s sex by marking the appropriate checkbox for 'Female' or 'Male.'
7. Record the approximate date of death in the specified format, mm/dd/yyyy.
8. Input the patient’s admission date using mm/dd/yyyy format.
9. Enter the reporter’s name, formatted as last name followed by first name.
10. For section B, denote the date and amount of the last opioid dose dispensed before the date of death.
11. Outline the treatment objective at the time of death by selecting one of the options provided: Induction, Maintenance, or Other.
12. Specify the opioid type used (, , or ) and the last dose given in milligrams.
13. Indicate the number of take-home doses dispensed at the last visit.
14. If applicable, indicate if the patient was undergoing medically supervised withdrawal (detox) at the time of death.
15. In section D, enter the most recent drug test date and the results.
16. Provide any medical and psychiatric diagnoses of the patient in section E.
17. In section F, identify the preliminary or confirmed underlying cause or mechanism of death, marking the appropriate options provided.
18. List any known over-the-counter (OTC) and prescription medications the patient was taking at the time of their last visit.
19. Write a detailed description of the event surrounding the patient's death, including relevant circumstances and any involved illicit drugs.
20. Include any other relevant medical history, such as allergies or preexisting medical conditions.
21. If known, provide the contact information of the medical examiner or coroner.
22. Review your entries for accuracy before finalizing your submission.
23. Once all sections are completed, you may save your changes, download the report, print it, or share it as necessary.

Start filling out the Samsha Otp Mortality Report Form online to ensure accurate reporting and contribute to the improvement of care in Opioid Treatment Programs.