worry.. how to write a proper post mortum note.

[lisawea]

someone pls help hw to document on a dead patient.today i have one of my patient pass, and i no ideal what to do or say. i wrote something but it do not look good or sound good.lol

[JustBeachyNurse, LPN]

What did you write?

[lisawea]

wrote called in res room @ 10:48. res was unresponsive.No heart or breath sound noted.No code was called. Due to resident DNR order sign in resident chart. Postmortem perform. Denture was place in resident mouth.Dr was notify. Next kin was notify.Foley cath removed. IV line removed for left forearm, and apply dry drag.Medical examination pick the body @ 12AM. All resident belonging check and given to resident family.

[jadelpn, LPN, EMT-B]

Time and date: Upon rounding on patient xyz, found said patient to be unresponsive. No pulse nor resp. Patient is a DNR/DNI. Protocol enacted. Charge nurse Mno notified. MD notified and pronounced at 1400 hours. Family notified at 1435.

1445: Post mortem care performed. POA Suzie advises as to calling the Whatever Funeral Home. Body release form signed. Personal belongings secured and labeled by Nurse Pdq and CNA Abc. Funeral director Whomever signed off on body release form at 1600 hours.

In most facilities there is a protocol regarding death of a patient. Be sure you follow it. Notifications, that the patient was pronounced and that there is a body release ready to go. And that you secure and document all personal belongings. Because death does weird stuff to people, you may find that every second cousin once removed wants to come in to "get the ring Grandma promised me" stuff--

Just be sure your documentation reflects everything that you do, and your follow your facility protocol.

[PomMom65]

I work on an inpatient Hospice unit, we would write something similar to this.

Mrs. X was admiited to our unit on 4/13/14 with a diagnosis of Pancreatic CA. She ceased to breath today, 4/18/14 at 310am. Her family was present at the time of her death. They are tearful but appropriate. Foley catheter was removed, left ac IV line was removed. All medication was wasted per policy, Please refer to the medication flow sheets for specific medications. The family took the patient's belongings home. Please refer to the valuables list. Coroner office was called and the patient's body was released to XYX funeral home at 6:05am.

[BrandonLPN, LPN]

Keep it short and sweet.

called into room by CNA at 0315. Resident found to be without pulse or respirations. Notified on-call physician, obtained order authorizing release of body. Notified Mary Smith, DPOA. Confirmed funeral home preference. Postmortem care performed. Body taken to morgue. Telephoned Quiet Oaks funeral home. Informed RN house supervisor.