AFTER A PATIENT DIES, nursing care includes preparing him for family viewing, arranging transportation to the morgue or funeral home, and determining the disposition of his belongings. You'll also comfort and support his family and friends and ensure privacy.
Postmortem care usually begins after a physician, nurse practitioner, or other advanced practice nurse certifies the patient's death. If the patient died violently or under suspicious circumstances, postmortem care may be postponed until the medical examiner completes an examination.
Document the date and time of the patient's death and the name of the health care provider who pronounced the death. If resuscitation was attempted, indicate the time it started and ended, and refer to the code sheet in the patient's medical record. Note whether the death is being referred to the medical examiner and whether an autopsy is being performed. Include all postmortem care given, noting whether medical equipment was removed or left in place. List all belongings and valuables and the name of the family member who accepted and signed the appropriate valuables or belongings list. Record any belongings left on the patient.
Document the disposition of the patient's body and the name, telephone number, and address of the funeral home. List the names of family members who were present at the time of death. If they weren't present, note the name of the family member notified and who viewed the body. Be sure to document any care, emotional support, and education given to the family.
Part of a good note might look like this:
7/22/08 1420-Called to room by pt.'s daughter, Mrs. Helen Jones, stating pt. not breathing. Pt. found unresponsive in bed at 1345, no respirations, no pulse, no heart or breath sounds auscultated. No code called per advance directive and signed DNR order in chart. Death pronounced by Dr. Holmes at 1350. NG tube, indwelling urinary catheter, and I.V. access device in L forearm removed and dressing applied. Postmortem care performed and dentures placed in mouth. Belongings checked off on belongings list and signed by Mrs. Jones, who will take them home with her. Body sent to morgue at 1415. Jeanne Ballinger, RN---
Source: Chart Smart: The A-to-Z Guide to Better Nursing Documentation, 2nd edition. Lippincott Williams & Wilkins, 2007.