MORTALITY REVIEW FORM 101906 216.3703
User Manual: 216.3703
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MORTALITY REVIEW Do not copy completed report Department of Medicine CQI/QA Confidential Patient Care Information Deliver completed form to C. Thomas Nuzum, CB# 7080, 4152 Bioinformatics Bldg Division Patient Name MR# Date Admitted Age Sex Transfer from outside hospita Death: Date Service Patient was: DNR Yes No Attending DNI Yes No Autopsy Yes M F Yes No , MD No Summary of events:_________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ The events surrounding the patient’s death were reviewed at a Division meeting on __________ (Date), paying particular attention to any possible actions or omissions that could have contributed to an untimely death of the patient. We conclude: ___ Death was expected and timely. ___ Death was unexpected but not preventable or modifiable in any important way by any reasonable actions by the UNCH care team. ___ Possibly preventable actions, complications, or omissions may have contributed to the death. Explain (briefly):_________________________________________________________________ ______________________________________________________________________________ _______________________________________________________________ (continue on back) Based on this case, the following: ___ Was done:_______________________________________________________ (continue on back) ___ Will be instituted:__________________________________________________ (continue on back) ___ Is recommended:_________________________________________________ (continue on back) We recommend the following topic(s) for departmental educational program(s): ___ This case for CPC ___ Other:_________________________________________________________________________ Completed By:________________________________ Pager:___________________ Date:___________________ Questions: Contact C. Thomas Nuzum, Phone 6-0808, Pager 216-9624, Fax 6-6842, E-Mail tom_nuzum@med.unc.edu or his assistant Steve Kennedy, Phone 6-2514, Pager 216-3703, skennedy@med.unc.edu
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