Is a discharge summary required when a patient dies in the hospital?

Discharge Summary Requirements for Deceased Patients

Yes, a discharge summary is required when a patient dies in the hospital, and it should be documented as a death summary containing specific elements about the circumstances and cause of death.

Death Summary Requirements

A death summary serves as the final medical documentation for a deceased patient and should include the following core elements:

Essential Components

• Patient identification information: Full name, medical record number, date of birth/age 1
• Date and time of death: Precise documentation of when death occurred 1, 2
• Location of death: Where in the hospital the patient died 1
• Cause of death sequence: Immediate cause of death and underlying causes in a logical chain 1
• Contributing conditions: Other conditions that contributed to death but were not part of the direct causal chain 1
• Clinical course: Summary of hospital admission, treatments provided, and progression leading to death 1
• Whether CPR was attempted: Documentation of resuscitation efforts or DNAR status 1, 2
• Whether family was present: Documentation of family presence at time of death 1
• Whether autopsy was performed or requested: Status of any post-mortem examination 1, 2

Additional Important Elements

• Life-sustaining treatments used: Documentation of mechanical ventilation, vasopressors, or other interventions 1
• Final vital signs and laboratory values: Relevant to the cause of death 1
• Neurological status: Final neurological assessment if applicable 2
• Discharge date: Should be recorded as the date of death 2

Best Practices for Death Summary Documentation

Content Quality

• Use clear, specific terminology rather than vague descriptions 1
• Present information in chronological order 1
• Differentiate confirmed diagnoses from suspected conditions 1
• Document the time CPR was initiated and stopped, if applicable 1

Special Circumstances

• For patients with do-not-attempt-resuscitation orders, clearly document this status 1
• For trauma-related deaths, include the nature of injuries and circumstances 1
• For infectious causes, specify the organism if known 1

Importance of Timely Completion

Timely completion of death summaries is crucial for:

• Accurate mortality data collection 2
• Communication with primary care providers 3
• Family closure and bereavement support
• Legal and administrative purposes

Common Pitfalls to Avoid

• Vague cause of death: Avoid non-specific terms like "cardiac arrest" without explaining the underlying cause
• Missing documentation: Ensure all interventions and their timing are documented
• Delayed completion: Death summaries should be completed promptly to ensure accurate information
• Inconsistent format: Follow standardized formatting for clarity 1

Death summaries serve multiple important purposes including quality improvement, research, legal documentation, and closure for families. They should be completed with the same care and attention to detail as discharge summaries for living patients, with particular attention to documenting the sequence of events leading to death.