History and Physical Advice Tips Secrets

Death Note

Residents have traditionally had little formal training in examining patients to determine death, notifying families, and in recording proper documentation.

The Phone Call: "Please come and pronounce this patient"
1. Find out the circumstances of the death - expected or sudden?; is the family present? What is the patient's age?

2. Preparation Before You Enter the Room

3. Get the details on the circumstances of death from the RN.

4. Find out if the attending physician has been called. In general, see the patient before you call the attending, unless there are unusual family dynamics or details surrounding the death that you should discuss prior to seeing the patient or family members in the room.

5. Has the family requested an autopsy? Do you see a value in requesting an autopsy?

6. Determine if the patient/family has already been contacted by the Organ Donor Network.

7. Review the chart for important medical (length of admission, cause of death) and family issues (who is family?, faith?, is there a clergy contact?).

In the Room
1. You may want to ask the nurse or chaplain to accompany you; he/she can give you support and introduce you to the family.

2. Introduce yourself (including your relationship to the patient) to the family if they are present. Ask each person their name and relationship to the patient.

3. Empathetic statements are appropriate: "I'm sorry for your loss..."; or "This must be very difficult for you...".

4. Explain what you are there to do. Tell the family they are welcome to stay if they wish, while you examine their loved one.

5. Ask if the family has any questions; if you cannot answer, contact someone who can.

The Pronouncement
1. Identify the patient by the hospital ID tag; Note the general appearance of the body.

2. Ascertain that the patient does not rouse to verbal or tactile stimuli. Avoid overtly painful stimuli especially if family members are present. Nipple or testicle twisting, or deep sternal pressure are inappropriate.

3. Listen for the absence of heart sounds; feel for the absence of carotid pulse.

4. Look and listen for the absence of spontaneous respirations.

5. Record the position of the pupils and the absence of pupillary light reflex.

6. Record the time at which your assessment was completed.

Documentation in the Medical Record
1. Called to pronounce (name); Chart findings of physical examination.

2. Note date and time of death; Note if family and attending physician were notified.

3. Document if family declines or accepts autopsy; Document if the coroner was notified.


History & Physical


Common Night Calls

Patient Tracker Sheets

Antibiotic Guide

ABG Calculator

Drug Guide

Medical Notes:
Admit/Transfer Orders
Progress (SOAP) Note
Discharge Summary
Procedure Note
Discharge Summary
Off-Service Note
Pre-Operative Notes
Operative Note
Post-Operative Note
Death Note
Post-Partum Note
Delivery Note
Cardiology Progress Note and Consult

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