Understanding the Mortality Review form is essential for those within the medical field, particularly in departments focused on continuous quality improvement and patient care. This document serves as a cornerstone in the evaluation of patient care, especially in instances leading to a patient's death. At its core, the form is designed to gather comprehensive details surrounding the events leading to a patient's demise, including the patient's name, medical record number, age, sex, admission and transfer details, as well as crucial decisions about Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders. The form facilitates an in-depth examination of whether the death was expected or if any preventable actions, complications, or omissions on the part of the healthcare team contributed to the outcome. Furthermore, it prompts a review of the case in a division meeting, focusing on evaluating the care provided and identifying any potential areas for improvement. This process culminates in recommendations for actions to be taken or introduced, and suggestions for educational programs within the department. Additionally, contact information for follow-up and further inquiries underscores the form's role in fostering a culture of transparency and continuous learning within healthcare institutions.
| Question | Answer |
|---|---|
| Form Name | Mortality Review Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | mortality case review template, mortality review worksheet for minnesota critical access hospital, hospital mortality review form, morbidity and mortality review template |
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
tom_nuzum@med.unc.edu or his assistant Steve Kennedy, Phone