Organ/Tissue Donation Referral Checklist
Ensure timely and appropriate referral to organ procurement organization per CMS requirements for all hospital deaths and imminent deaths.
- Industry: Healthcare
- Frequency: Every death/imminent death
- Estimated Time: 10-15 minutes
- Role: Clinical Staff
- Total Items: 29
- Compliance: CMS CoP 42 CFR 482.45, UNOS Policies, OPO Policies
Clinical Triggers
Referral trigger criteria
- Imminent death identified?
- Ventilator-dependent?
- Meeting neurological death criteria?
- Cardiac death/withdrawal of support?
OPO Notification
Timely OPO referral
- OPO called within timeframe?
- OPO case number obtained?
- Clinical information provided to OPO?
- OPO recommendations documented?
Donor Suitability
OPO determination
- Medical suitability determined by OPO?
- Potential organ donor?
- Potential tissue donor?
Family Approach
Authorization process
- Family approach decoupled from death notification?
- OPO staff approached family (if applicable)?
- Authorization obtained?
- All documentation complete?
Pre-Assessment Information
Initial assessment documentation and patient/facility identification
- Assessor Name / Credentials
- Assessment Date
- Department / Unit
- Assessment Type (Routine/Annual/Complaint)
- Previous assessment findings reviewed?
Infection Prevention & Control
Verify infection control practices per CDC and Joint Commission standards
- Hand hygiene compliance observed?
- Appropriate PPE available and properly used?
- Isolation precautions properly implemented?
- Sharps containers available and not overfilled?
- High-touch surfaces properly disinfected?
Patient Safety & Identification
Verify patient safety protocols and identification procedures
- Two patient identifiers used before procedures?
- Fall risk assessment completed?
- Call light within patient reach?
- Bed in lowest position with brakes locked?
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Why Use This Organ/Tissue Donation Referral Checklist?
This organ/tissue donation referral checklist helps healthcare teams maintain compliance and operational excellence. Designed for clinical staff professionals, this checklist covers 29 critical inspection points across 7 sections. Recommended frequency: every death/imminent death.
Ensures compliance with CMS CoP 42 CFR 482.45, UNOS Policies, OPO Policies. Regulatory-aligned for audit readiness and inspection documentation.
Frequently Asked Questions
What is a Organ/Tissue Donation Referral Checklist?
A Organ/Tissue Donation Referral Checklist is a standardized inspection form used by clinical staff to ensure consistent healthcare operations. It contains 36 inspection points organized into 7 sections. FREE organ donation referral checklist PDF. CMS CoP and UNOS compliant. Timely OPO notification, family approach, clinical triggers. Download FREE template now.
How often should I use this healthcare checklist?
This checklist is designed to be completed every death/imminent death. Regular use ensures compliance with CMS CoP 42 CFR 482.45 and UNOS Policies and helps identify issues before they become problems.
Can I download this Organ/Tissue Donation Referral Checklist as a PDF?
Yes, you can download this checklist as a FREE PDF for printing or offline use. The checklist includes 36 fields across 7 sections and typically takes 10-15 minutes to complete.
What compliance standards does this checklist cover?
This checklist helps ensure compliance with CMS CoP 42 CFR 482.45, UNOS Policies, OPO Policies. Following these standards protects your organization and ensures best practices.
How do I complete this healthcare inspection checklist?
Begin by completing the header fields for Patient Name, MRN, Trigger Event, Referral Date/Time, and Referring Staff. Work through each of the 7 sections, marking items Yes or No as applicable. Add notes for any issues found. Finally, complete the footer fields and add your signature. The entire process takes approximately 10 to 15 minutes.
What are the key sections in this healthcare checklist?
This healthcare checklist is organized into 7 key sections: Clinical Triggers, OPO Notification, Donor Suitability, Family Approach, Pre-Assessment Information, Infection Prevention & Control, Patient Safety & Identification. Each section contains specific inspection points that clinical staff must verify. The structured layout ensures nothing is missed during healthcare inspections and makes the process efficient, typically taking 10-15 minutes to complete.
Who should use this Organ/Tissue Donation Referral Checklist?
This checklist is primarily designed for clinical staff working in healthcare operations. However, it is also valuable for quality assurance teams, safety officers, compliance managers, and supervisors who need to verify that healthcare standards are being met. Organizations of all sizes can benefit from using this Organ/Tissue Donation Referral Checklist to maintain consistency and accountability.