Death is an inevitable part of life. While dealing with the loss of a loved one can be emotionally and physically draining, organizations have developed processes to provide support for the affected family during this difficult time. One such process is known as the Mortality Review Form (MRF). This standardized form is designed to help organizations assess their safety protocols when a death occurs in order to prevent future fatalities. In this blog post, we'll take an in-depth look at what exactly goes into an MRF review process and how it can offer peace of mind to those most adversely impacted by tragedy.
| 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