Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Date of Death:
Attending Physician:
Summary of Admission
Briefly state the reason for the patient’s admission.
Include the admitting diagnosis, date of admission, and relevant past medical history.
Hospital Course
Provide a concise overview of the patient’s clinical course during their stay.
Include key interventions, responses to treatment, and any complications encountered.
Mention any significant investigations or procedures performed.
Cause of Death
State the primary cause of death based on your clinical judgment and available evidence.
If the cause of death is unclear, mention that an autopsy is pending or recommended.
Contributing Factors
List any contributing factors that may have influenced the patient’s outcome.
These may include co-existing medical conditions, complications of treatment, or social determinants of health.
Interventions at Time of Death
Briefly describe the resuscitation efforts undertaken, if any.
Specify the time at which death was pronounced.
Family Notification
Document that the patient’s next of kin or designated healthcare proxy were notified of the death.
Disposition of Remains
Briefly mention any information regarding the release of the body to the funeral home or family.
Autopsy (Optional)
If an autopsy was performed or is recommended, document this here.
Specimens Sent for Pathology (Optional)
If any tissue samples were sent for further examination, list them here.
Final Notes
Include any additional pertinent details specific to the patient’s case.
Important Note:
This template is not a substitute for completing a legal death certificate, which is a separate medico-legal document.
Always consult your local guidelines and regulations for completing death certificates.
Additional Considerations:
When documenting a death, strive for sensitivity and respect for the deceased and their family.
Ensure the information is accurate and complete to aid in future medical record reviews and public health data collection.