SOP 508.03-att-1: Offender Death Notification Form

Division:
Office of Health Services
Effective Date:
July 13, 2020
Reference Code:
VG03-0001
Topic Area:
508 Policy-MH Administration/Staff/Certification
PowerDMS:
View on PowerDMS
Length:
176 words

Summary

This form is used by facility mental health staff to document and report the death of an incarcerated individual to the Office of Health Services within 48 hours. The form collects information about the deceased offender, circumstances of death, mental health history, medical diagnoses, medications, and treatment contacts. Completed forms are submitted via fax and become part of the offender's permanent mental health file, which is retained for 10 years.

Key Topics

  • offender death notification
  • death reporting
  • mortality review
  • mental health documentation
  • cause of death
  • psychiatric history
  • psychotropic medications
  • suicide prevention
  • inmate death
  • facility reporting

Full Text

SOP 508.03
Attachment 1

7/13/20

GEORGIA DEPARTMENT OF CORRECTIONS Name:________________________________________

Offender Death Notification Form ID#:__________________________________________

Facility:____________________________________ DOB:_________________________________________

Date:______________ Time:___________________ Race:_________________ Sex:____________________
**********************
This Offender Death Notification form must be completed by the facility mental health staff and FAXED to Office of
Health Services (478-992-5865) within 48 hours following the offender's death.
**********************
Information Concerning the Death:

Date of Death: ____/_____/_____ Location:_________________________________________________________

Manner of Death: [ ] Hanging [ ] Exsanguination [ ] Overdose Suspected [ ] Homicide

Place of Death: [ ] GP [ ] Isolation/Segregation [ ] SLU [ ] Infirmary [ ] CSU/ACU/Observation Cell

[ ] Other _________________________________________

Mental Health Level of Care: __________ Mental Health Diagnosis:_________________________________________

Medical Diagnosis/conditions:_________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Psychotropic Medication(s):___________________________________________________________________________

__________________________________________________________________________________________________

Medication Adherence:_______________________________________________________________________________

Last three (3) Mental Health Counselor Contacts:__________________________________________________________

Last three (3) Psychiatric Contacts:_____________________________________________________________________

An Institutional Mental Health Mortality Peer Review panel has been scheduled to meet on ______/_______/_____

Comments:________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Signature__________________________________ Completed on ______/_____/______ Faxed on _____/_____/_____

Form no. M03-01-01

Retention Schedule: Once completed, the original shall be placed in the offender’s mental health file (section 1). At the end of the offender’s need for mental health
services and/or sentence, the mental health file shall be placed within the offender’s health record and retained for 10 years.

Attachments (2)

  1. Offender Death Notification Form (176 words)
  2. Offender Critical Incident Notification Form (202 words)
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