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

Not documented

Insurance:

Private/Commercial insurance

Medicare

Medicaid

Health Maintenance Organization (HMO)

No insurance/self-payment

Other insurance

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 #___________________________________________________

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

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)

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) ___/____/___

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)?

SID#______

Symptoms/Problems

Refer to progress and nursing notes for the day of death and the day before.

SID#______

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

DRAFT. ã Copyright: J.M. Teno and by The Center to Improve Care of the Dying, 1997
Permission granted for non-commercial use only.