Death/Pronouncement Note (Hospice)

Patient: [Patient name], [DOB], [MRN]

Hospice Diagnosis: [Terminal diagnosis]

Location of Death: [Address or facility name and room]

Setting: [Home / ALF / SNF / Inpatient Hospice / Other]

Date/Time Pronounced: [Pronouncement date and time]

Pronouncing Clinician: [Name], [Credentials], [Role]

Death Summary

[Brief narrative summarizing whether death was expected in the context of the terminal illness; who discovered the patient and approximate time; whether resuscitation was initiated and why or why not with reference to code status; and the general disposition plan] (Include timeline elements as available: last known alive, time found unresponsive, time hospice notified, time clinician arrived, time assessment completed. If death was not directly witnessed, note the source of timeline information and any uncertainty.)

Pronouncement Examination

Identification Method: [How patient identity was verified, e.g., name band, photo, family confirmation, facility staff]

Clinical Findings: [Findings confirming death] (Document: unresponsive to stimulation; no spontaneous respirations and no breath sounds; no palpable pulse and no heart sounds; pupils fixed and non-reactive. Include additional methods only if performed.)

Time of Death: [Actual or presumed time of death] (If different from pronouncement time, document both and the basis for the presumed time.)

Notifications & Disposition

(Document key notifications in brief log format. Include only those applicable.)

• [Family/Next of Kin]: [Time] — [Outcome]
• [Hospice supervisor/medical director]: [Time] — [Outcome]
• [Attending physician]: [Time] — [Outcome]
• [Facility staff]: [Time] — [Outcome]
• [Funeral home]: [Time notified] — [Estimated arrival]

ME/Coroner: [Yes / No] — [If yes: time called and instructions received. If no: basis for not reporting]

Body Release: [Who authorized release], [Body location pending pickup], [Special considerations if applicable] (Note pacemaker/ICD if cremation planned.)

Medication Safety

Controlled Substances Present: [Yes / No] — [If yes, note whether secured after death]

Counseling Provided: [Summary of disposal counseling given to family] (Include take-back programs, approved home disposal methods, and keeping medications secured.)

Disposal Actions: [Performed / Not performed] — [If performed: date/time, who performed, witnesses, method. If not performed: plan including who will dispose and by when.]

Bereavement Handoff

Primary Contacts: [Names and relationships], [Preferred contact method]

Immediate Needs: [Observed coping, supports present, known risk factors or urgent needs]

Follow-up Plan: [Bereavement referral sent to], [Planned outreach timeline] (Note if services offered and declined.)

Electronic Signature: [Clinician name], [Credentials] — [Date/Time]

Co-Signature: [Name], [Credentials] — [Date/Time] (If required by policy.)