When a patient dies, you need the following 5 items:
– EMR order: Patient discharge/expiration order
– EMR form: Patient expiration note
– EMR form: Discharge summary (to be written by the primary resident if you are covering while on call)
– Paper form: Fill out gift of life form (usually check off declined and then sign)
– Paper form: Death certificate
This is the physical exam macro I have created, please feel free to save as a macro yourself! If you would like, I can send an example death certificate to have on file as reference. It is extremely particular!
Pronunciation of Death
I was paged by patient’s RN at [enter time here] to notify me that patient was unresponsive. I arrived to bedside at [enter time here].
Patient was examined as documented below.
CONSTITUTIONAL – The patient is unresponsive to verbal stimuli and sternal rub.
HEENT – Pupils are fixed and dilated. There is no corneal reflex.
LUNGS – No chest rise noted. No breath sounds auscultated.
HEART – No heart sounds auscultated. Asystole on monitor.
EXT – Pulses in the femoral, radial and carotid are absent bilaterally
Presumed time of death:
Pronounced time of death:
The family is at bedside
Gift of life contacted by RN.
Medical examiner does not need to be contacted for this patient.
Option of autopsy discussed with family, declines at this time.
Death certificate completed, handed to unit clerk. Attending physician notified of patient death and management.