|
|
|
|
END-OF-LIFE CHART
REVIEW - ADMINISTRATIVE INFORMATION
Date ___________ End of Life Chart Review--Administrative Information SID#_______ Chart Abstractor # _______ ______________________________________________________________ Last Name, First Name, MI _____/_____/____ ____/_____/______ _______ Date of Birth Date of Death Age ___M / F_________________________ Sex Social Security Number Race/Ethnicity: Religion: 1. White/Caucasian 0. None (not religious) 2. Black/African American 1. Jewish 3. Asian or Pacific Islander 2. Orthodox Jewish 4. Other 3. Catholic (Roman or 5. Hispanic Orthodox) 6. Native American 4. Jehovah's Witness 7. Not documented 5. Christian Scientist 6. Seventh Day Adventist 7. Protestant (and all other Christian) 8. Other
Insurance:
Copyright: Center to Improve Care of the Dying, 1997 SID# ________ Next of Kin: Name ________________________________________________________ Relationship___________________________________________________ Address______________________________________________________ _____________________________________________________________ Telephone #___________________________________________________ Is a surrogate or health care proxy named? ______________ Surrogate name ___________________________________________ Relationship ________ ___________________________________________ Address (if different from next of kin)_________________________________ ______________________________________________________________ Telephone #___________________________________________________ Copyright: Center to Improve Care of the Dying, 1997 Date ________ Chart Abstractor # _____ SID # ________ End of Life Chart Review--Inpatient ______/_____/_____ ______/____/____ Date of admission Date of death Diagnosis and Status _______________________ DRG# ________________________________________________________________ Primary diagnosis, ICD-9 code ________________________________________________________________ Secondary diagnoses, ICD-9 codes ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Procedures, ICD-9 codes Copyright: Center to Improve Care of the Dying, 1997 SID# _________ 0=no, 1=yes, 9=not applicable. All information should be obtained from progress notes and orders. Were any of the following formal directives noted: _____ Living Will ____ DPOAHC ____ Values History ____ Medical Directive ____ Any other advance directive/combined directives Date of first formal advance directive chart documentation: ____/____/___ _____ Was a Do Not Hospitalize (DNH) order noted? _____Is there any interpretation as to how the advance directive applies in the current situation in the physician's progress notes? _____ Do Not Resuscitate (DNR) ___/___/___ (first date) _____ Do Not Intubate (DNI) ___/___/___ (first date) _____ Comfort measures only ___/___/___ (first date) _____ Full code documented ____/___/___ (first date) Copyright: Center to Improve Care of the Dying, 1997 SID#_______ Sentinel Decisions All information should be obtained from physician's progress notes and orders.
0=no, 1=yes, 9=N/A Resuscitation ____ Patient resuscitated during or just before entry into the hospital ____ Documentation of conflict between: ____ patient and surrogate ____ patient and physician ____ surrogate and physician ____ Resuscitation forgone: date ___/___/___ ____ Resuscitation tried--heart beat established, consciousness regained before death: date(s) ___/____/___ ____ Resuscitation tried--heart beat established, no consciousness regained before death: date(s) ___/____/___ Copyright: Center to Improve Care of the Dying, 1997 SID # _______ ICU ____ Was patient in an ICU at the time of death or within the last 2 calendar days (0=no, 1=yes)? Dates in an ICU (note admit and discharge dates) ____________ Total number of days in an ICU ___________________________ ____ Was discharge from ICU expecting death (0=no, 1=yes, 9=N/A)? Copyright: Center
to Improve Care of the Dying, 1997 Symptoms/Problems Refer to progress and nursing notes for the day of death and the day before.
Copyright: Center to Improve Care of the Dying, 1997 SID#______ Treatments Administered 0=no, 1=yes; for the day of death and the day before. Refer to progress notes. ____ antibiotics ____ family emotional needs are noted ____ Chaplaincy consult ____ chemotherapy regimen _________________________________________ focus on palliation (not life prolonging) _________________ ____ enteral tube (NG/peg/G) ____ foley catheter ____ intravenous fluid ____ intravenous medication ____ intubation ____ narcotics (as noted in administrative records) max narc dose, last full calendar day before death: ____________ ____ physical restraints ____ surgery in the OR type: ___________________________________________ ____ ventilator Diagnostics 0=no, 1=yes; for the day of death and the day before. Refer to progress notes and orders. ____ A line ____ blood draws, #: ______________________________________________ ____ Swan ____ x-rays Copyright: Center to Improve Care of the Dying, 1997
|
|
|
|
||
|
This web site is published by the Center for Gerontology and Health Care Research, Brown Medical School. For further information, e-mail Dr. Joan Teno or contact her at Brown Medical School, Box G-HLL, Providence, RI, 02912, USA. For questions or comments regarding this website, please e-mail the webmaster. Last edited February 17, 2004. |
||||
