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.
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.
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.
SmartText: AHS IP HEADINGS DECEASED NOTE
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.
SmartText: AHS IP BASIC DECEASED NOTE
Problem-Oriented Charting (POC)
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.
SmartText: AHS IP POC DECEASED NOTE
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.
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.
This section can be used to provide a succinct overview of the patient's reason and mode of presentation initiating the encounter. The more advanced templates (e.g., Problem-Oriented Charting [POC]) have interactive features allowing structured data to be used to compose a consistent overview.
Most Responsible Encounter Diagnosis
This mandated information should reflect the admitting diagnosis, presenting complain or principle hospital problem. More advanced templates assume that this information has already been entered to the chart; and then pull it in automatically. Interactive (dark blue) text can be selected to update the source data.
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. Advanced templates allow the section header (dark blue text) to be selected for rapid access to revisions of the date/time of death and the preliminary cause of death.
Health problems addressed during the inpatient or emergency department encounter are listed in this section. More advanced templates pull this information in automatically, with interactive links to the problem list activity where additions and edits can be entered.
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. More advanced templates pull this information in from the Hospital or ED course 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.
An optional (SmartList controlled) interventions text block facilitates summarization of the major (operative or procedural) interventions performed during the encounter.
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).
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.