DEATH PRONOUNCEMENT NOTE

Patient: [Name]
Date of birth or ID: [Identifier]
Location: [Unit and room]
Date: [Date]
Pronounced by: [Name, credentials, role]
Attending: [Name]

CALL AND CIRCUMSTANCES
Called by: [Name, role, and time of the call]
Reason: [Breathing stopped, found unresponsive, or resuscitation stopped]
Arrived: [Time]
Expected or unexpected: [Diagnosis, recent course, and whether death was expected]
Code status: [Do-not-resuscitate order, comfort care, or full code; any resuscitation, its length, and when it stopped]
Identity confirmed: [Wristband, name, and date of birth checked]

EXAMINATION
Response: [No response to voice or to a painful stimulus, and which stimulus]
Pupils: [Fixed and dilated, no response to light]
Breathing: [No spontaneous breathing; no breath sounds, and how long you listened]
Heart and pulse: [No heart sounds, and how long you listened; no carotid or femoral pulse]
Monitor: [Rhythm on the monitor, or not attached]
Observation: [Total time observed, per your policy]

PRONOUNCEMENT
Time of death: [Time pronounced; the time breathing was last seen, if different]
Present: [Family, staff, chaplain, or no one]
Presumed cause: [Immediate cause and underlying condition, or unknown]

NOTIFICATIONS
Family or decision-maker: [Name, relationship, time, in person or by phone, and who told them]
Family response: [Questions asked, wishes about time with the patient, spiritual or cultural needs]
Attending or primary physician: [Name, time, and how]

CORONER OR MEDICAL EXAMINER
Reportable: [Yes or no, and the reason under your jurisdiction's rules]
Reported to: [Name or office, time, and case number]
Instructions: [Lines and tubes left in place, samples kept, release of the body]

DONATION AND AUTOPSY
Donation referral: [Time called, reference number, outcome, and who will speak with the family]
Autopsy: [Offered, and accepted or declined by whom; or for the coroner or medical examiner to decide]

AFTER DEATH
Death certificate: [Who will complete it, and when]
Body: [To the morgue or the family's funeral home, and when]
Belongings: [Listed, and given to whom]
Support offered: [Chaplain, social work, or bereavement services]

Signed: [Name, credentials, date and time]