Complete patient medical records required of a health
facility pursuant to regulations adopted by the department in
accordance with Section 1275 shall be kept, maintained, and preserved
with respect to the requirements of this chapter when an individual
is pronounced dead by determining that the individual has sustained
an irreversible cessation of all functions of the entire brain,
including the brain stem.
(a) Each general acute care hospital shall develop a protocol
for identifying potential organ and tissue donors. The protocol
shall require that any deceased individual's next of kin or other
individual, as set forth in Section 7151, at or near the time of
notification of death be asked whether the deceased was an organ
donor or if the family is a donor family. If not, the family shall be
informed of the option to donate organs and tissues pursuant to
Chapter 3.5 (commencing with Section 7150) of Part 1 of Division 7.
With the approval of the designated next of kin or other individual,
as set forth in Section 7151, the hospital shall then notify an organ
and tissue procurement organization and cooperate in the procurement
of the anatomical gift or gifts. The protocol shall encourage
reasonable discretion and sensitivity to the family circumstances in
all discussions regarding donations of tissue or organs. The protocol
may take into account the deceased individual's religious beliefs or
obvious nonsuitability for organ and tissue donation. In the event
an organ and tissue procurement organization does not exist in a
region, the hospital shall contact an organ or a tissue procurement
organization, as appropriate. Laws pertaining to notification of the
coroner shall be complied with in all cases of reportable deaths.
(b) A general acute care hospital shall comply with subdivision
(a) or (c) as a condition of participation in the Medi-Cal program
contained in Chapter 7 (commencing with Section 14000) of Part 3 of
Division 9 of the Welfare and Institutions Code.
(c) Notwithstanding subdivision (a), the protocol may alternately
provide for the hospital to contact an organ and tissue procurement
organization at the time a potential organ and tissue donor is
identified, and for the trained personnel of the organ and tissue
procurement organization to make the inquiries described in
subdivision (a) of the deceased individual's next of kin or other
individual as set forth in Section 7151.
(a) In conjunction with entering into any agreement with
any coroner or medical examiner for release and removal of organs
from bodies within that official's custody and to further the
purposes of Section 27491.45 of the Government Code, a procurement
organization shall develop a protocol for organ recovery, as
appropriate, that provides sufficient information on the medical and
injury status of the deceased to permit release and removal of organs
without undue prejudice to that official's investigation of, or
inquiry into, the cause of death.
(b) The protocol described in subdivision (a) shall be subject to
approval by the coroner or medical examiner before release or removal
of organs and shall provide for the following:
(1) Relevant information on the deceased to be given to the
coroner or deputy coroner at the time of the initial request for
permission to recover internal organs, including, but not limited to:
(A) Information identifying the deceased.
(B) Date and time of pronouncement of brain death.
(C) Name of procurement organizations and coordinator.
(D) Organs requested.
(E) Organ donor number and hospital.
(F) Apparent cause and manner of death.
(G) A brief description of alleged circumstances surrounding the
death to the extent they are known at the time.
(H) The law enforcement agency and the name of the investigating
officer handling the case.
(2) The following information, to be recorded by the organ
procurement coordinator at the time of requesting permission for
(A) The name of the deputy coroner contacted.
(B) The name of the pathologist contacted by the deputy coroner.
(C) Whether permission for removal was obtained at the time,
including the date and time if permission was obtained.
(D) The coroner's case number assigned by the deputy coroner.
(E) If the request for organ removal is refused, the reason given
for the refusal.
(3) A checklist to be completed prior to recovery of any organ by
the procurement organization coordinator with the assistance, if
necessary, of a physician attending the deceased, that includes, at a
minimum, all of the following:
(A) medical record review to insure documentation of external
injuries, fractures, and internal injuries.
(B) In cases of suspected child abuse, whether:
(i) A child abuse consult was obtained.
(ii) A computerized axial tomographic scan or magnetic resonance
image of the head was obtained.
(iii) A radiological skeletal survey was done.
(iv) The presence or absence of visible injury to the back of the
scalp, ears, nose, and mouth, or retinal hemorrhage has been
(v) A coagulation screen report was in the deceased's records.
(C) A photographic record of visible external injuries.
(D) Admitting blood sample, if available, and the date and time
the sample was drawn.
(4) A checklist of items to be provided to the coroner's office
when the deceased's body is released after completion of organ
recovery, including, but not limited to, all of the following:
(A) A copy of the deceased's medical records.
(B) Film documenting abnormal findings, if used.
(C) The information recorded pursuant to the requirements of this
(D) A sample of the deceased's blood, if taken on admission.
(5) A form, completed by the physician and surgeon, technician, or
team performing the organ recovery procedure and signed by the
physician and surgeon, that describes in sufficient detail all of the
(A) Tests used to determine the suitability for transplantation of
all organs recovered.
(B) Documentation of injuries and other abnormalities, if any,
noted or occurring during the organ recovery procedure.
(C) The date and time organ recovery was started.
(D) Any other information on the state of the deceased's body or
organs that the physician and surgeon, technician, or team believes
may assist the coroner in his or her investigation or inquiry.
(c) The requirements of subdivision (a) shall not apply in any
county that does not have a Level II trauma facility, as defined in
Section 1798.160 and the regulations adopted pursuant thereto.
(d) Notwithstanding any other provision of law, a health care
provider may release the information described in this section to the
procurement organization, the coroner, or the medical examiner.
(e) For purposes of this section, "organ" or "organs" means
internal whole organs, including, but not limited to, the heart,
kidneys, the liver, and lungs, but does not include eyes, skin, or
other similar tissue.