Daily Progress Notes (The “SOAP” note)
The Death Note
The death note is a medical-legal document that is written on each patient that expires during hospitalization. The note should be written at the time of death and includes:
• The name of the patient, the time and date the note was written.
• A description of the events leading to the death of the patient
• If the patient was comfort measures only (CMO) at the time of death
• If the patient expired within 24 hours of admission and if so if a medical examiner was contacted.
• A physical exam
• Time of death
• If the attending of record was notified
• If the family was notified
• Documentation that an autopsy was requested by medical staff
• Funeral home arrangements
• Signed legibly by author
The note below is an example of a death note.
Death Note
Date:
Time:
MD/DO
I. Please describe events leading to death:
Was the patient Comfort measures only (CMO) Yes No
Did the patient expire within 24 hours of Admission Yes No
Was a medical examiner contacted Yes No
II. Patient Exam:
Response to verbal or tactile Stimuli None
Spontaneous respiration None
Heart sounds and pulses None
Pupillary response Fixed and dilated
III. Time of death:
IV. Attending physician notified: Yes No
V. Family notified: Yes No
VI. Autopsy: Yes No
VII. Funeral Home Arrangements:
Signature with pager number
[pic]
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