OCPHD Overdose Report

Overdose Report
Notification Date

MonthDayYear
Date
Facility Name
Type a question
Optional: Reporter Name
Optional: Reporter Contact Phone NumberFormat: (000) 000-0000.
Calculated Age
Years Old
PATIENT INFORMATION
Patient's Name
Patient's Birth Date

MonthDayYear
DOB
Address

Street Address

Unit, Apartment, Space or Trailer number

CityState

Zip Code
Is the patient homeless or unhoused?
Gender
Ethnicity
Race (Mark all that apply)
Substance(s) suspected/reported
Date of Overdose Event

MonthDayYear
Date
Location of Encounter
City where Overdose Event occurred
Naloxone administered?
Number of Naloxone doses
Did they respond to Naloxone?
Patient Disposition
Transported to hospital by

Other
Transported to Hospital for
Not transported to Hospital because
Expired from overdose: Death Date

MonthDayYear
Date
Expired from overdose: Coroner notified?
Case Definition for Reportable Overdose
An overdose should be reported if considered by the reporter to be life threatening, or in the case of a fatality to be due primarily to a drug overdose (OD). The report should occur regardless of the substance(s) thought to be responsible. This definition is not meant to include indirect effects of substance use such as the risk associated with driving while intoxicated
Case Definition for Reportable Overdose read & understood?
Confidentiality and Follow-Up Considerations
Your facility is being asked to report all drug overdoses (OD’s) to the Okanogan County Public Health District (OCPHD) rather than issuing a “Health Order” mandating this reporting as a notifiable condition. The opioid epidemic like any epidemic, is tracked over time by public health. In addition, although an OD is a medical condition resulting from drug poisoning, some who experience overdoses may have substance use disorders for which treatment can be offered. The opportunity to offer such help is a second important reason for making OD’s notifiable. Okanogan Behavioral Health Care is to receive these reports from OCPHD IF patient signs referral follow-up for substance use disorder and wants help. These procedures are adopted to assure patient confidentiality and compliance with HIPAA and CFR 42.
Confidentiality and Follow-Up Considerations read & understood?
Should be Empty:

Overdose Report

PATIENT INFORMATION