Deceased Documentation

A "deceased" note is a special instance of a discharge summary. Discharge summaries must be prepared for all patients who die during an inpatient encounter or an emergency department encounter. Those discharge summaries should use an AHS provincially standardized "deceased note" template within the discharge summary.

A "deceased navigator" is available to both inpatient and emergency providers. It helps clinicians to ensure that arrangements have been made, communications sent, orders closed and documentation completed. When the discharge summary section of a deceased navigator is used to create a new note, this automatically initiates a deceased note template within a discharge summary note type.

AHS Deceased Note Template

The default deceased note template allows users to select the type and complexity of note needed. The user is presented with a single, simple SmartList. The available selections allow the user to determine how SmartTools are used to template and complete a discharge summary for a deceased patient.

Blank

A blank note has no headings or content. Users will select this when they already have a personalized deceased note template to use in place of the provincial standards. That personalization should comply with the expected sections, label wording, ordering and minimum content.

Headings 

A headings note template sets up a deceased note discharge summary with expected header identifiers as well as all required sections. Users can use SmartTools or dictation to enter content for each section. Wildcards (***) are provided to ease moving from section to section.

Basic 

A basic note template sets up a deceased note discharge summary with expected header identifiers, all required sections and common content pulled from other sections of the chart. Users can use SmartTools or dictation to enter additional details. SmartLists and wildcards (***) are provided to facilitate entry of some content.

Advanced

A POC note template sets up a deceased note discharge summary with expected header identifiers, all required sections and common content from other sections of the chart, as well as text composed from data captured as part of POC workflows. SmartLists and wildcards (***) are provided to facilitate entry of some content.

Specialty Variants

Deceased notes differ somewhat, depending upon whether a patient dies in the emergency department or an inpatient setting. Other differences might reflect unique circumstances of some specialty contexts (e.g., obstetrics and delivery). 

If an AHS standard IP template (selected from deceased note entry SmartList or initiated with any of the above listed SmartTexts) is used, it will automatically detect a different clinical context (e.g., emergency department) and switch to the appropriate specialty or context variant.

If a needed specialty variant is not yet available in an AHS standard template format, it is suggested that users select the "Blank" or "Headings" option and add specialty-specific content as appropriate. Use help.connect-care.ca to submit a request to have a standardized specialty template developed and added to the automated substitutions.

Standard Deceased Note Sections

AHS summative documentation standards expect a discharge summary for an encounter ending in patient death to include certain headings and content. The different deceased templates described above have more or less SmartTools and interactive features to pre-populate this content from the digital health record. Remember to use the "refresh" button to updated SmartTool content before saving or signing.

Header

The top (header) section of a deceased summary records encounter bounds (e.g., admission and discharge dates), accountable providers, information about the facility and the goals of care designation active at the time of death. Note that some text (usually labels) is in a dark blue font. Selecting this text will open parts of the chart where the relevant data is stored. Ideally, the data will be updated in its proper chart location. Then the deceased summary can be refreshed to pull that data into the template.

Overview

This section can be used to provide a succinct overview of the patient's reason and mode of presentation initiating the encounter. The basic and advanced templates have interactive features allowing structured data to be used to compose a consistent patient overview.

Most Responsible Diagnosis

This mandated information should reflect the admitting diagnosis, presenting complaint or principle hospital problem. The basic and advanced templates pull the data in automatically. Interactive (dark blue) text can be selected to update the principle problem.

Preliminary Cause of Death

A preliminary cause of death must be included in a deceased note. It is entered in the deceased navigator (found within the discharge navigator) when the time and date of death is recorded. The section header (dark blue text) can be selected for rapid revision of the date/time of death and the preliminary cause of death.

Hospital Problems

Health problems addressed during the inpatient or emergency department encounter are listed in this section. Basic and Advanced templates pull this information in automatically, with interactive links to the problem list activity where updates can be made.

Hospital Course

The hospital course section should be used to provide a high-level, concise, ideally point-form summary of key developments during the inpatient or emergency department encounter. Basic and Advanced templates pull this information in from data already in the health record. Interactive headings (dark blue text) allow for edits to the source content before refreshing and updating in the template.

Interventions

An optional (SmartList controlled) interventions text block facilitates summarization of the major (operative or procedural) interventions performed during the encounter.

Autopsy

An optional (SmartList controlled) autopsy text block indicates whether more information about problems contributing to death will be available later by virtue of autopsy or other post-mortem investigation(s).

Finding Standardized Summative Documentation Templates

Standardized deceased summary templates (Headings, Basic, Advanced) can be found and used by three easy means:

Blank Note with SmartLink

A blank note can be initiated within the inpatient chart "Notes" activity. Be sure to select the correct Note Type (Discharge Summary) and charting service (inpatient provider service most responsible at the time of discharge) at the top of the note editor. The following dot phrases can be used to pull in one of the three standardized templates.

Discharge Navigator Speed Button

The "Discharge as Deceased" section of the Discharge Navigator (present in all inpatient charts when a prescriber is logged on) has a "Discharge Summary" section near the bottom of the navigator. This reminds that other navigator tasks should be completed before a discharge summary is composed.

Speed buttons are provided for Headings, Basic and Advanced templates. Clicking on the desired button will open a note editor with the correct document type and template automatically loaded.

Chart Sidebar Link

The inpatient chart sidebar is present by default as a collapsible right-most section of all opened inpatient charts. It has a "Notes" item (bottom left column of index). Selecting this presents a secondary sidebar menu that includes a link for "Discharge Summary". Selecting this, in turn, presents a list of standardized discharge summary templates, including those for deceased patients. All are links. Selecting the appropriate one will open a note editor with the correct note type and template pre-loaded.

Pending, Sharing and Signing Discharge Summaries

Connect Care automatically shares key summative documents with the Alberta Netcare Portal electronic health record and with eDelivery-compatible electronic medical records (EMRs). Automated sharing is triggered when an eligible note is signed (co-signed in the case of trainee-authored notes). If the same note is later edited and re-signed, a new copy is distributed to external systems. 

Summative document contributors should “pend” or “share” their work, saving "signing" for the most responsible prescriber after all reviews are complete. A document should be signed just once; and so shared just once.

Death Certificates

The Province of Alberta is working on, but does not yet support, digital death certification. At this time, responsible physicians must complete a formal (paper) death certificate in the event of a patient death. These can be found at Emergency or Nursing Station forms stores. They can also be obtained from the facility admitting department and must be returned to medical records before a body can be released.

Resources