Surrogate Selection Checklist Form (Page 3 of 4) in pdf

Surrogate Selection Checklist Form Page 3

Patient Name ____________________________________________ Hospital # ______________________

d. Demonstrate care and concern for the patient?

Yes ____

No ____

If yes, enter the basis for this decision:

e. Visit the patient regularly during the illness?

Yes ____

No ____

f. Engage in FACE-TO-FACE contact with the caregivers?

Yes ____

No ____

g. Fully participate in the decision-making process?

Yes ____

No ____

6. Is person available and willing to serve as surrogate?

Yes ____

No ____

If no, select the best qualified person who is available and willing to serve and enter name

7. Is this person the highest person in the list from #4?

Yes ____

No ____

If no, or if there are several persons at the same priority level, enter the reasons why the selected

person is more qualified under factors 5 a-g above.

_________________________________________________________________________________

8. If conscious, the patient must be notified of the determination of incapacity and who the patients

surrogate will be.

Date and time when notified: _________________________________________________________

Record patient response: _____________________________________________________________

9. If the determination of incapacity is for a patient with psychiatric mental illness, mental retardation,

or addiction, incapacity must be confirmed by another physician or licensed psychologist who has

examined the patient. Is this necessary for this case? Yes ____ No ____

10. If yes, has this been done? Yes ____ No ____

If so, name of second health care professional declaring the patient incapacitated

________________________________________________________________________________

11. Were other potential surrogates notified of surrogate selection? Yes ____ No ____

If yes, enter names, date, time and by whom they were contacted.

Surrogate Selection Checklist Form Page 3