Quick Note Template for a Deceased Patient
A comprehensive deceased patient note should include immediate after-death care documentation, family notification details, and completion of necessary medical and legal documentation. 1
Patient Identification and Death Information
- Patient name, medical record number, date of birth 1
- Date and time of death 1
- Location of death (e.g., hospital unit, home) 1
- Patient's status at time of death (e.g., "Patient was deceased at the end of the call") 1
Death Certification and Medical Details
- Cause of death as officially recorded 1
- Whether resuscitation was attempted or if the patient had DNAR/NFR orders 1
- Removal of tubes, drains, lines, and foley catheter (unless autopsy is planned) 1
- Documentation of any organ donation considerations or discussions 1
Family Notification and Support
- Documentation of family notification (who was notified, when, by whom) 1
- Record of time provided to family to be with the body 1
- Documentation of culturally sensitive, respectful treatment of the body 1
- Condolences offered to family 1
Administrative and Legal Documentation
- Confirmation that death certificate was filed 1
- Documentation of forms completed for funeral director 1
- Record of other healthcare providers notified of the patient's death 1
- Documentation of any autopsy discussions or plans 1
Bereavement Support
- Plan for formal condolences (e.g., card, call, letter) 1
- Referral to appropriate bereavement services 1
- Identification of family members at risk for complicated bereavement 1
- Plan for follow-up debriefing meeting with family if desired 1
Healthcare Team Support and Reflection
- Documentation of medical issues related to the patient's death 1
- Record of family's emotional responses 1
- Documentation of staff's emotional responses 1
- Plan for bereavement ritual for staff if appropriate 1
Common Pitfalls to Avoid
- Incomplete documentation of time and cause of death 1
- Failure to document family notification details 1
- Omission of cultural or religious considerations in after-death care 1
- Inadequate documentation of organ donation discussions 1
- Missing signatures or authentication of the death pronouncement 2
Using a standardized template for deceased patient documentation significantly improves thoroughness and completeness of documentation compared to handwritten notes 3, ensuring all essential elements are properly recorded for both medical and legal purposes.