What constitutes a comprehensive hospice summary to chart after a patient expires?

Comprehensive Hospice Summary Documentation After Patient Death

A comprehensive hospice summary after patient death should document the circumstances of death, symptom management at end-of-life, family presence and support provided, and confirmation of post-death procedures completed. 1

Essential Components of Hospice Death Summary

Patient Status Documentation

• Document exact time of death and who pronounced the patient 2
• Record patient's status at the end of care (deceased) 2
• Note location of death (home, inpatient hospice, hospital) 2
• Document who was present at time of death (family members, caregivers) 2

End-of-Life Symptom Management

• Document final symptom management interventions provided:
  • Pain control measures and effectiveness 2
  • Management of dyspnea (oxygen, positioning, medications) 2
  • Anxiety management (benzodiazepines, emotional support) 2
  • Management of terminal secretions (anticholinergics if used) 2
  • Any palliative sedation if required for intractable symptoms 2

Family Support Documentation

• Record family/caregiver presence at time of death 2
  • Who was present
  • Who was notified after death
• Document emotional/spiritual support provided to family 2
• Note any immediate bereavement support offered 2
• Document any cultural or religious rituals performed 2

Post-Death Procedures

• Confirm notification of physician 2
• Document notification of funeral home/mortuary 2
• Record removal of any medical devices (ICD deactivation, LVAD discontinuation) 2
• Note disposition of medications/supplies 1
• Document time body was removed and by whom 2

Quality Indicators to Address

• Whether death occurred in preferred location 2
• Whether patient was free from avoidable distress and suffering 2
• Whether family was prepared for the death 2
• Whether advance directives were honored 2
• Whether spiritual/existential needs were addressed 2

Documentation Template Example

Date/Time of Death: [Date/Time]
Death pronounced by: [Name/Credentials]
Location of death: [Home/Facility]

Present at time of death: [Names/Relationship]
Family members notified: [Names/Relationship/Time]

Final symptoms and management:
- Pain: [Status and interventions]
- Respiratory: [Status and interventions]
- Neurological: [Status and interventions]
- Other symptoms: [Status and interventions]

Emotional/spiritual support provided: [Description]
Cultural/religious practices observed: [Description]

Post-death procedures:
- Physician notified: [Name/Time]
- Funeral home notified: [Name/Time]
- Medical devices removed: [Yes/No/Details]
- Medications/supplies disposition: [Details]
- Body removed: [Time/By whom]

Initial bereavement support provided: [Description]
Follow-up bereavement plan: [Details]

Quality indicators:
- Death occurred in preferred location: [Yes/No]
- Patient appeared comfortable at death: [Yes/No]
- Family prepared and supported: [Yes/No]
- Advance directives honored: [Yes/No]

Common Pitfalls to Avoid

• Failing to document exact time of death and who pronounced it 2
• Omitting details about symptom management in final hours 2
• Neglecting to document family presence and notification 2
• Incomplete documentation of medical device deactivation/removal 2
• Missing documentation of cultural/spiritual care provided 2
• Failing to note initial bereavement support offered 2

By following this comprehensive documentation approach, you ensure continuity of care for the family through bereavement, provide important information for quality improvement, and create a complete medical-legal record of the patient's final care.