Death documentation

How to Document Death Confirmation

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In addition to knowing how to perform death confirmation, it’s important to understand how to appropriately document it in the notes. This guide provides a structured approach to documenting death confirmation in a patient’s notes. To see how to complete a death certificate check out our dedicated guide.


Documentation basics

Before we discuss how to document the death confirmation, we need to cover the basics that apply to all documentation in a patient’s notes. You can check out our detailed guide to writing in the notes for more information.

What should I use to write with?

You need to use a pen with black ink, as this is the most legible if notes are photocopied.

Patient details

For every new sheet of paper your first task should be to document at least three key identifiers for the relevant patient:

  • Full name
  • Date of birth
  • Unique patient identifier
  • Home address

If a patient label containing at least 3 identifiers is available, then this can be used instead of writing out the information manually.

Location details

You should indicate the patient’s current location on the continuation sheet:

  • Hospital
  • Ward
    Patient details

     


Beginning your entry in the notes

At this point, you should already be holding a pen with black ink and you should have ensured the continuation sheet has at least three key patient identifiers at the top.

The next documentation steps include:

1. Adding the date and time (in 24-hour format) of your entry.

2. Writing your name and role as an underlined heading.

3. Adding your entry in the notes below this heading (see the next section for details).

Beginning an entry in the notes

 


Documenting death confirmation in the notes

1. Document your reason for attending and if relevant, who asked you to attend (e.g. asked to confirm the death of Mr Smith by staff nurse Amanda Miles).

2. Document who was present whilst you were confirming the death (e.g. staff members and/or the deceased patient’s family and friends).

3. Document the circumstances of the death:

  • Location of the patient
  • The individual who first noted the patient to be dead
  • Any individual present at the moment of death

4. Document confirmation of death assessment:

  • Identity confirmed by wrist band
  • General inspection
  • No signs of respiratory effort
  • No response to verbal stimuli
  • No response to painful stimuli
  • No pupillary response to light
  • No central pulse
  • No heart sounds after 3 minutes of auscultation
  • No respiratory sounds after 3 minutes of auscultation

The recommended time for auscultation varies, but typically at least 5 minutes of auscultation of heart and respiratory sounds are advised to establish that irreversible cardiorespiratory arrest has occurred.¹

5. Document the outcome of the assessment, including the time of death (which should be documented as the time at which you completed your assessment).

6. Document any discussions you had with staff members or relatives of the deceased in relation to the death.

7. Document any concerns of staff members or the patient’s relatives.

Death confirmation documentation

 


Completing the entry in the notes

At the end of your entry to need to include the following:

  • Your full name
  • Your grade/role (e.g. F2/Medical Registrar)
  • Your signature
  • Your professional registration number (e.g. GMC number)
  • Your contact number (e.g. phone/bleep)
Completing the entry in the notes

 

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