❏ Yes: ________________________________________________ ❏No….Tattoos/piercing ……………………………….. Page 1 of 3 Tissue Donor Physical Assessment Schematic Recovery Agency ID: _______________________ ❏Check ❏Check if no observations noted if no observations noted Key to Schematic: Abrasion Body piercing requires description – Bruise/Contusion/Hematoma Urethral catheter Cast/Ortho device Skin lesion requires description – Dressing/Bandage Scar (surgical/trauma) ET tube/NG tube Rash Fracture/Dislocation Ocular Donation IV/IO/Arterial Line Tattoo requires description (also note if suspected to be new) – Skin Tag(s) Stretch mark(s) ID Band/ Tag Mole Laceration/Wound Team Blood Draw Site Autopsy Incision ___________________________________________________ Needle entry site ___________________________________________________ Organ Recovery Incision ___________________________________________________ ___________________________________________________
❏No….Tattoos/piercing ……………………………….. ❏ Yes: ________________________________________________ Page 1 of 3 Tissue Donor Physical Assessment Schematic Recovery Agency ID: _______________________ ❏Check if no observations noted ❏Check if no observations noted Key to Schematic: Abrasion Bruise/Contusion/Hematoma Cast/Ortho device Dressing/Bandage ET tube/NG tube Fracture/Dislocation IV/IO/Arterial Line Skin Tag(s) ID Band/ Tag Laceration/Wound Autopsy Incision Needle entry site Organ Recovery Incision Body piercing – requires description Urethral catheter Skin lesion – requires description Scar (surgical/trauma) Rash Ocular Donation Tattoo – requires description (also note if suspected to be new) Stretch mark(s) Mole Team Blood Draw Site ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________