OCPHD Overdose Report

Overdose Report
Notification Date*

MonthDayYear
Facility Name*
Optional: Reporter Name
Optional: Reporter Contact Phone Number
Calculated Age
Years Old
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?

NoYesUnknown
Gender*

FemaleMaleOtherUnknown
Ethicity

Hispanic or LatinoNot Hispanic or LatinoUnknown
Race (Mark all that apply)

Alaskan NativeAsianBlack/African AmericanNative American IndianNative HawaiianOther Pacific IslanderWhiteOtherUnknown
Substance(s) suspected/reported
Date of Overdose Event*

MonthDayYear
Date Overdose occurred
Location of Encounter
City where Overdose Event occurred*
Naloxone administered?*

NoYes
Number of Naloxone doses
Did they respond to Naloxone?

NoYesUnknown
Patient Disposition*

Transported to hospitalNot transported to hospitalExpired from overdose
Transported to hospital by

EMSPOVOther
Transported to Hospital for

Evaluation in ER & releasedHospitalized >+ overnight
Not transported to Hospital because

Not needed; unnecessaryRefused
Expired from overdose: Death Date

MonthDayYear
Date
Expired from overdose: Coroner notified?

NoYesUnknown
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?*

Yes
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?*

Yes
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