The Death Documentation template allows you to produce a cremation form electronically and send via email, as well as recording details of death, adding verification, adding Medical Examiner notes, Coroner referral and After Death Analysis.
It can be found within Auto-consultation > ardens CONDITIONS C to D > Death Documentation
There is also a link from the Reception & Administration template.
It can also be added to F12 favourites for quick access.
The video below gives an overview of how the template can be used throughout the process of documenting a patient's death
The template is split into several tabs across the top, to make it easier to navigate to the area you wish to complete:
This first section gives an overview of any relevant information and coding for your information.
The Verification tab allows you to record specific codes to clearly document the verification of the death of the patient. This is divided into 3 sections - 'Pre-Authorisation', 'Verification' and 'Covid-19'.
The 'Pre-Authorisation' section is where you can code if the patient is close to death and also record that a 'Verification of expected death agreement is documented'. There is a link to launch this Agreement in word to the right of this code, which you can save to the patient record, print out and sign. You can also record a DNACPR Status here if the patient doesn't already have one, and to the right of this is a link through to the Future Care Planning template where you can record more information on this if required.
The 'Verification' section has all the criteria to verify the patients death and record this onto the patients notes.
The 'Covid-19' section is where it can be recorded if Covid-19 may have affected the provision of an assessment on this patient or if anything had to be done remotely.
Recording the Patient's death
A member of the Reception or Administration teams can use the Details tab of the 'Death Documentation' template to record the details for the Patient's death. This page is a quick way of capturing all necessary information and a useful prompt for the questions to ask where appropriate.
The 'Information' link next to 'Device Status' will take you through to the Devices & Implants tab where you can view if the patient has any of the listed devices in the box below. To return to the 'Details' tab once you have viewed this to continue filling out the rest of the information just click back on the 'Details' tab at the top.
You can also print out a handy 'Bereavement Info' leaflet for the relatives of the deceased which lists useful numbers for them to call to register the death etc. Just tick the box next to 'Bereavement counselling' to code you have given this, and click on the 'Bereavement Info' button next to this to launch this leaflet in word where you can print it out and save it to the record.
You can also inform the GP about the patient's death and whether a cremation form needs to be done by either using the 'New Task' button or adding to the 'Visits' screen.
There are also tick boxes at the bottom of the template to code that the MED A Form has been given to the family and/or sent to the Registrar.
This section is for the medical examiner (an independent doctor) to complete or to specify 'Referral to coroner' before a death certificate is issued.
The cause of death can be added which will auto-populate the cremation form.
This allows you to create a referral to the coroner and document the reason. Contact Details should list the coroner contact telephone number (if using Ardens Pro) under the 'Community' tab.
Click on Coroner Referral to create the referral document.
There is a notes section to allow free text and below document the outcome.
Here you can record whether a Post Mortem has been requested or received using the drop down box, and fill in any information regarding this in the notes box below it.
The 'Certification' tab is divided into 3 sections - 'Criteria', 'MCCD' and 'Crem Form'.
The 'Criteria' section allows you to follow the Royal College of Pathologists pathway on when the attending physician is not available. Answer the relevant questions and the guidance will update below on who can complete the MCCD and/or the Crem Form. There is also a link to the side to the actual criteria this is based on.
The 'MCCD' section allows you to record the relevant codes on creating a Death Certificate and record the different causes of death, and the reasons for concluding the cause of death.
Creating the Cremation form
The GP writing the cremation form can view the details that have been recorded at the previous stage by viewing the Tabbed or New Journal.
The GP can then open the 'Death Documentation' template from auto consultations > ardens GENERAL or from F12 favourites and complete the 3. Certification and 4. Cremation parts of the template
We have provided both Crem Form 4+5 (Parts 1+2) and Form 4 only (Part 1) depending on which is needed at the time.
To ensure any new information added to the template is merged through into either of these documents, you will need to click OK on the template and reopen. This will ensure any information you have just added will pull through in to the Crem Form.
To make it easier to reopen the template, add the Death Documentation template to F12 favourites
Select either Crem From 4+5 or Form 4 only open the cremation form as a pre-completed form to print, take to the body and sign. The printed version will also include the Part 2 by default meaning this can be taken to the crematorium too to be signed by a second practice.
Find out how to add a digital signature in word.
Email Part 2 to a neighbouring Practice
To email an unsigned copy to a neighbouring practice, click the 'Send by Email' button.
This will list the newly created cremation form in a window. Place your mouse in the window and right click > Send via NHS Mail and select the practice from your SystmOne address book (the email address will need to be added as an address book entry).
The receiving practice can use this as notification that a Part 2 needs to be done and then call the sending practice to discuss. The receiving practice can either print the Part 2 and take to the crematorium to sign or simply turn up to sign the Part 2 that the sending Practice has printed and taken. This can of course be decided between GPs or decided as part of a local practice policy.
Notification of Death
This page allows you to record which teams or organisations you have notified of the patients death by ticking the relevant box. There is also a button to send to staff a 'New Notification' or a 'New Notification of Death' task depending on local policies.
There is also the option to produce a 'Notification of Death Letter' which will merge into word and then send to the relevant organisations you have ticked above. Any existing letters you might have produced will sit in the box below this, which you can right click on and view, or even send via NHS Mail.
After Death Analysis
This page allows you to record the details around recording an After Death Analysis of the patient.
In the 'Details' section you can record specific details to do with the death of the patient using the drop down boxes.
The 'Counselling' section will allow you to record who has been contacted with information on counselling, and even allow you to produce a 'Bereavement Letter' which will open in word with some useful contact details you can give to the family or friends of the patient. The 'SUDEP Bereavement Letter' will open up a similar letter but for epilepsy related deaths.
The 'Analysis' section will allow you to create an 'ADA' form, either with merge fields or blank, which you can then fill out within word. There is a link to the 'LeDeR Notification Form' on an external website and at the bottom of the template there is a blank box to write any other free text notes you may feel is appropriate.
Devices & Implants
This page can be linked to from pressing the 'Information' button on the 'Details' page of the template. The template will list the sorts of battery powered or other implants that could cause a problem at cremation, and in the box at the bottom, if there are any such devices that have been coded in the notes of the patient, they will appear here.
If the box is empty, it is likely that none of these devices have been recorded, but this is not a complete list so it is worth double checking the patient and their full medical record.
A list of useful links. These can be sent via SMS or Email by highlighting the link, Copying with Ctrl+C, clicking on 'Send Message' and then pasting with 'Ctrl+V' into the relevant box.