11/13/24, 7\:41 PM Guide | Documenting death confirmation

Documenting death con

Table of contents

Introduction

In addition to knowing how to perform death con, it's important to document the process accurately in the medical
notes.
This guide provides a structured approach to documenting death con
completing a death certicerti.

Documentation basics

Before we discuss how to document the death con
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
Full name
Date of birth
Unique patient identi
Home address
If a patient label containing at least three identi
information.

Location details

You should indicate the patient's current location on the continuation sheet\:
Hospital
Ward
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Patient identi

Starting your entry

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 identi
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).
Starting your entry in the notes
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Documenting death con

1. Document your reason for attending and, if relevant, who asked you to attend (e.g. asked to con
sta
2. Document who was present while you con
friends).
3. Document the circumstances of the death\:
Location of the patient
The individual who
Any individual present at the moment of death
4. Document the con\:
Identity con
General inspection\: no signs of life or respiratory e
No palpable central (carotid) pulse*
No heart sounds on auscultation*
No respiratory sounds on auscultation*
Any other monitoring used to con
Absence of pupillary re
Absence of motor response to supra-orbital pressure
* The patient must be observed for at least
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 sta
7. Document any concerns of sta
Documenting death con

Completing the entry

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At the end of your entry to need to include the following\:
Your full name
Your grade/role (e.g. medical registrar, nurse practitioner)
Your signature
Your professional registration number (e.g. GMC number, NMC pin)
Your contact number (e.g. phone/bleep)
Source\: geekymedics.com
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