Documentation for DC Dictations when Someone Dies/ Doing Death Certificates

A discharge summary done when someone passes should be done with the same criteria as any discharge summary - within 48 hours or less (stat), diagnosis list including primary and secondary causes of death, list of significant procedures, history/physical exam, hospital course with major highlights. Documentation of code discussions, family discussions, and mode of passing/code/events should be included. Instead of "discharge planning" a discussion of counseling done and ancillary staff (chaplaincy called) should also be included.

By TN law, a licensed physician should be completing the death certificate within 48 hours but the TN Office of Vital Records acknowledges the difficulty of this. Death certificates which are signed later than 4 days are reviewedby the state. Therefore, it is important for residents and faculty to discuss the appropriate listing of the cause of death and that it is consistent between the death summary and death certificate. Cardiopulmonary arrest, for instance, is a mode of death but not the cause. Myocardial infarction is a cause of death. This can be due to 1 or more factors (coronary artery disease, for example). The death certificate asks for approximate amount of time of the diagnosis prior to death (days, weeks, months, years can be listed generally). The death certificate also asks for contributing diagnosis or significant diagnosis that may not have been direct cause of death (diabetes, prostate cancer, etc). It would be beneficial to include this level of detail in the dictation.

An online module providing education about death certificates and deciding on the cause of death is available through UT Memphis for free: http://www.uthsc.edu/cme/TN_death_certificate/index.php