Institutional Patient Death Record Form PDF Details

For any healthcare institution, one of the most important tasks is to accurately and meticulously record patient deaths. Being able to document a patient's last moments with a structured document like an institutional patient death record form is crucial for the safety and care of future patients by ensuring that medical mistakes are avoided or repeated. In this blog post, we will take a look at what goes into recording these vital pieces of information in an institutional setting and how it helps protect patients as well as healthcare personnel.

QuestionAnswer
Form NameInstitutional Patient Death Record Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesinstitutional death record online, ipdr ontario, institutional death form, institutional patient death record

Form Preview Example

Office of the Chief Coroner

Institutional Patient Death Record

For use by facilities to which the Long-Term Care Homes Act 2007 applies, for the mandatory report required when a resident dies in the facility or off the premises and in the care of a Long-Term Care Home staff member.

Where a resident dies on the premises of a long-term care home, to which the Long-Term Care Homes Act, 2007 applies, or off the premises and in the care of a Long-Term Care Home staff member, the Coroners Act requires that the death be immediately reported to a coroner. Online submission of this form is requested.

INSTRUCTIONS:

1.Please complete this form immediately after a resident dies in the circumstances noted above.

2.After answering the 8 questions below:

(a)If all answers to the 8 questions below are “No”, submit the completed form. No call to the coroner is required.

(b)If there are one or more “Yes” answers, please call Coroner DispatchIMMEDIATELY to report the death, and record the name of the coroner assigned in the field below, then submit the form.

Please direct any inquiries to:

 

 

 

Office of the Chief Coroner

 

 

 

occ.inquiries@ontario.ca

Coroner Dispatch Telephone: 416 314-4100 / 1 855 299-4100

 

 

 

 

 

Deceased Last Name

 

Deceased First Name

 

 

 

 

 

 

 

 

 

Age

 

Date of Death (yyyy/mm/dd)

Time of Death

Male

Female

 

 

 

 

 

 

 

 

 

 

Institution Name

Institution Address

Unit No.

Street No.

Street Name

PO Box

City/Town

Province

Postal Code

1. Accidental Death?

(An accident is an event that caused unintended injuries that begin the process leading to death. The time interval between the injury and death may be minutes to years. For example, a hip fracture is a common injury that begins the process that leads to death in the elderly. If there is a possible connection between a fracture or an injury and the events leading to death, the death should be reported to the local coroner).

Yes

No

2. Suicide?

(Death due to an external factor initiated by the deceased.)

3. Homicide?

(Death due to an external factor initiated by someone other than the deceased.)

Yes

Yes

No

No

*If there is a possibility of suicide or homicide, telephone both the police and the coroner, remove any other residents and seal the room until they arrive.

4. Undetermined?

Yes

 

(The manner of death is unclear. There is some reason to think that the death may not be due to natural

 

causes, but it is not clearly an accident, a suicide or a homicide.)

 

5.

Is the death both sudden and unexpected?

Yes

 

 

 

(i.e. The death was not reasonably foreseeable.)

 

6.

Has the family or any of the care providers raised concerns about the care provided to the deceased?

Yes

 

 

7.

Has there been a recent increase in the number of deaths at your Long-Term Care Home?

Yes

 

 

8.

Has there been a recent increase in the number of transfers to hospital?

Yes

 

 

No

No

No

No

No

Last Name of Person completing this form

First Name

Title

Telephone No. (incl. area code)

Signature

Date Completed (yyyy/mm/dd)

Last Name of Local Coroner (if a local coroner was called)

First Name

Telephone No. (incl. area code)

0153E (2011/04) ©Queen's Printer for Ontario, 2011

Disponible en français

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