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# Age Sex
M F
Date Admitted Transfer from outside hospita Yes No
Death: Date Service Attending , MD
Patient was: DNR Yes No DNI Yes No Autopsy Yes 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
