What are the guidelines for finalizing nursing notes after a patient's death?

Guidelines for Finalizing Nursing Notes After a Patient's Death

Nursing notes after a patient's death should be completed comprehensively, documenting the death process, family notification details, and all post-mortem care provided, following established protocols for deceased patient documentation.

Documentation Requirements Following Patient Death

Essential Documentation Elements

• Document patient identification information, including name, medical record number, and date of birth 1
• Record the date, time, and location of death precisely 1
• Document the official cause of death as determined by the physician 1
• Note any resuscitation attempts or presence of DNAR/NFR orders 1
• Document the removal of medical devices, tubes, and lines (unless an autopsy is planned) 2, 1
• Record family notification details, including who was notified, when, and by whom 1

End-of-Life Care Documentation

• Document any rituals or practices that were performed to facilitate a peaceful death 2
• Record the presence of family members at time of death or if they were absent 2
• Document any meaningful last words or gestures of the patient that may help family members in their grieving process 2
• Note any cultural or religious considerations that were addressed in after-death care 2, 1

Administrative Documentation

• Confirm that the death certificate was filed and document this confirmation 1
• Record completion of forms for the funeral director 1
• Document notification of other healthcare providers about the patient's death 1
• Note any organ donation discussions or decisions 1

Family Support Documentation

Immediate Support

• Document time provided to the family to be with the body 1
• Record any emotional support provided to family members 2
• Document any information shared with family about the dying process if they were not present 2
• Note any dignified photographs shared with bereaved family (with permission) 2

Bereavement Support

• Document plans for formal condolences such as cards or calls 2, 1
• Record referrals to bereavement services 2, 1
• Identify and document family members at risk for complicated grief 2
• Note any bereavement resources provided to the family 2

Team Communication and Support

Interdisciplinary Communication

• Document communication between physicians and nurses regarding the patient's death 2
• Record any debriefing sessions held following difficult cases 2
• Document any support provided to staff members experiencing grief 2
• Note any memorial rituals performed by the healthcare team 2

Quality Improvement

• Document any lessons learned or concerns about quality of care 2
• Record any follow-up plans with family members to assess coping 2
• Note any feedback received from family members about the end-of-life care 2

Common Pitfalls to Avoid

• Avoid incomplete documentation of time and cause of death 1
• Do not fail to document family notification details 1
• Avoid omission of cultural or religious considerations in after-death care 2, 1
• Do not leave out documentation of emotional support provided to family members 2
• Avoid inadequate documentation of organ donation discussions 1
• Do not delay completion of nursing notes after a patient's death, as timely documentation is essential for accuracy 3

Finalizing the Nursing Note

• Complete all documentation as soon as possible after the patient's death to ensure accuracy 3
• Ensure all entries are dated, timed, and signed according to facility policy 1
• Review the note for completeness before finalizing 1
• Follow institutional protocols for closing out the deceased patient's chart 1
• Document any pending follow-up with family members 2