What should be included in a nursing note for a deceased patient?

Comprehensive Nursing Documentation for Deceased Patients

A comprehensive deceased patient nursing note should include patient identification, death information, medical details, family notification, administrative documentation, and bereavement support to ensure proper care and legal compliance. 1

Essential Components of Deceased Patient Documentation

Patient Identification and Death Information

• Document complete patient identification including name, medical record number, and date of birth 1
• Record the exact date, time, and location of death 1
• Document the presence or absence of family members at the time of death 1

Medical Details and Certification

• Record the cause of death as officially determined 1
• Document any resuscitation attempts or the presence of DNAR/NFR orders 1
• Note the removal of medical devices, tubes, and lines (unless autopsy is planned) 1
• Document any end-of-life care provided, including pain management and symptom control 2
• Record the physician who pronounced the death 1

Family Notification and Support

• Document who was notified of the death, when, and by whom 1
• Record the time provided to family members to be with the body 1
• Note any cultural or religious considerations addressed in after-death care 1, 2
• Document emotional support provided to family members 1
• Record any meaningful last words or gestures of the patient that may help family in their grieving process 1

Administrative and Legal 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 2

Bereavement Support

• Document plans for formal condolences (card, call) 1
• Record referrals to bereavement services 1
• Identify and document family members at risk for complicated grief 1
• Note any bereavement resources provided to the family 1

Important Considerations for Quality Documentation

Ensuring Dignity and Respect

• Document how the body was prepared with dignity and respect 2
• Record any rituals or practices performed to facilitate a peaceful death 1
• Note how cultural and spiritual preferences were honored 2

Team Communication

• Document communication between physicians and nurses regarding the patient's death 1
• Record any debriefing sessions held following difficult cases 1
• Note any support provided to staff members experiencing grief 1

Common Pitfalls to Avoid

• Avoid incomplete documentation of time and cause of death 1
• Don't fail to document family notification details 1
• Ensure cultural or religious considerations in after-death care are not omitted 1, 2
• Don't neglect documentation of organ donation discussions 1
• Avoid poor documentation of spiritual and psychosocial issues, which are frequently missed in end-of-life documentation 3

Final Documentation Steps

• Ensure all entries are dated, timed, and signed 4
• Complete any required incident reports if the death was unexpected 1
• Document any follow-up plans with family members 1
• Record any feedback received from family members about the end-of-life care 1

Following these comprehensive guidelines ensures that nursing documentation for deceased patients is complete, accurate, and supports both the legal requirements and the emotional needs of families during this difficult time.