Comprehensive Death Summary Components

Patient Identification and Death Information

The American Heart Association recommends that patient's full name, medical record number, and date of birth should be clearly documented 1
The American College of Cardiology suggests that date, time, and location of death must be recorded precisely 2, 1
Document whether the patient died during hospitalization or after discharge, as recommended by the American Heart Association 3
Record the place of death (e.g., hospital ward, ICU, emergency department), as suggested by the American College of Cardiology 2, 1

The American College of Cardiology recommends documenting the underlying cause of death (the disease or condition that initiated events leading to death) rather than just the mechanism of death 4
Avoid using non-specific terms like "cardiorespiratory failure" which describe mechanisms rather than causes, as recommended by the American College of Cardiology 4
Specify cardiovascular causes precisely (e.g., myocardial infarction, arrhythmia, cardiogenic shock), as suggested by the American College of Cardiology 4
Document how the cause of death was determined (clinical judgment, laboratory findings, imaging), as recommended by the American Heart Association 2, 5

The American Heart Association recommends documenting any resuscitation attempts, including methods used (e.g., bag-mask ventilation, intubation, mechanical ventilation) 6
Note the presence of Do Not Attempt Resuscitation (DNAR) or Not For Resuscitation (NFR) orders if applicable, as suggested by the American College of Cardiology 3
Record airway and ventilation requirements prior to death, as recommended by the American Heart Association 2, 6

The American College of Cardiology suggests including a brief summary of the patient's hospital course leading to death 1
Document vital signs and neurological status prior to death, as recommended by the American Heart Association 6
Record any complicating illnesses that developed during hospitalization (e.g., respiratory distress syndrome, sepsis, acute renal failure), as suggested by the American College of Cardiology 2, 5

The American College of Cardiology recommends recording which family members were notified of the death 1
Document who provided the notification and when it occurred, as suggested by the American College of Cardiology 1
Note if family members were present at the time of death, as recommended by the American College of Cardiology 1

Confirm that the death certificate was filed and by whom, as recommended by the American College of Cardiology 1
Document forms completed for the funeral director, as suggested by the American College of Cardiology 1
Record other healthcare providers who were notified of the patient's death, as recommended by the American College of Cardiology 1

The American College of Cardiology recommends documenting plans for formal condolences (e.g., card, call) 1
Record referrals to bereavement services, as suggested by the American College of Cardiology 1
Identify family members at risk for complicated grief, as recommended by the American College of Cardiology 1

Incomplete documentation of time and cause of death, as warned by the American College of Cardiology 1
Using vague terminology for cause of death (e.g., "cardiorespiratory failure"), as warned by the American College of Cardiology 4
Failure to document family notification details, as warned by the American College of Cardiology 1
Omission of cultural or religious considerations in after-death care, as warned by the American College of Cardiology 1