Tag: legal

Documentation, prioritisation, and handover

Documentation, prioritisation, and handover

Vani and Sam give suggestions on how to improve these everyday skills that can otherwise take a lifetime to learn.

 Why is this important?

  • Decisions will be made based on documentation – we are lazy and tend not to verify information.
  • Allows you to organise your thoughts, review notes, and identify gaps.
  • Is a legal record and part of your job description.
  • Inadequate documentation sinks careers.
  • You will not remember the details years later if there is a complaint. HDC cases tend to occur years after the fact.
  • Prioritisation is an art and is learnt through experience. It is however important to know what the expectations are and not cause harm through poor prioritisation.

Types of documentation

  • Ward round notes
  • HO notes
  • Ward call notes
  • Plans
  • Lab requests
  • Referrals
  • Clinic letters
  • Procedure notes
  • Op notes
  • Discharge summaries
  • Sick notes
  • Supporting letters
  • Death certificates

All documentation

  • Title
  • Date/time
  • Reason for review/note
  • 1 line summary
  • SOAP (Subjective, Objective, Assessment, Plan) or HEIIP (History, Exam, Investigations, Impression, Plan)
  • Pertinent info
  • Solid plan
  • Your name + pager
  • Never change a note


  • Let time heal
  • Trust no one (nonsensical pages, reflux, nebs)
  • Complete non-urgent tasks ward by ward
  • Document a plan nurses can follow
  • Talk to the nurse
  • Hand over a plan with any jobs
  • Give a reason for jobs (e.g. fluid review)
  • Handover on time, handover your jobs
  • Don’t come to work sick
  • Perfect is the enemy of good.


  • What makes a good handover?
  • Concise and objective
  • Clear plan for pending results
  • Clear priority
  • Concise! Most of what you say will be forgotten, so make it count.
  • Why is it important?
  • Safety!
  • Helps with prioritisation
  • Opportunity to discuss cases with a colleague
  • Allows you to relax and sleep after you’ve gone home
  • What is appropriate to handover?
  • Jobs to be done
  • Investigations to be chased and plan
  • Patients to be reviewed
  • Sick patients
  • Patients expected to die
  • Patients for whom you feel additional context would be useful. Don’t just hand over patients the next house officer “might get paged about”.
  • Go home on time.
  • Weekend plan
  • Prepare discharge summaries and referrals
Verifying and certifying death

Verifying and certifying death

Update March 2018

Since recording, a pilot electronic death certification project has launched. See these resources:

The MOH has also released some new guidance to completion of the death certificates and including cause of death. See the resources section at the bottom of this post.

Despite its significance, the verification and certification of death are tasks few RMOs excel at. Sam talks to Dr Garry Clearwater, FACEM and Medical Referee, about the practical aspects of verifying death, and completing the paperwork.

Verifying death

  • Must be done “immediately after a doctor learns of the death” (within reason).
  • Body clearly in a state incompatible with life (rigor mortis, decomposition, major injury) or;
  • Absence of:
    • Heart sounds, ideally a minute
    • Breath sounds
    • Pupil reactivity
    • Muscle tone
  • Recheck if in doubt, or do a rhythm strip
  • It’s okay to backdate the time of death to when you think it actually occurred.

Clinical notes

  • If death verified using a standard approach, simply note absence of vitals on examination.
  • Otherwise, document details that lead you confirm death.

Cause of death

  • Part 1 may be a clear underlying fatal condition e.g. metastatic colon carcinoma, severe dementia.
  • In part 2, list conditions that would modify your approach to further treatment of the primary cause of death e.g. dementia, cancer, severe cardiac or pulmonary disease.
  • List enough information for the medical referee to understand why the patient died and further treatment or intensive care was withheld.
  • If the cause was idiopathic, say so, otherwise list the underlying cause.
  • Remember to state the obvious, and don’t agonise about making a final diagnosis if it remains uncertain.
  • Importance of cause of death:
    • Used to make resource and funding decisions based on death statistics.
    • May have implications on surviving family members (genetic predisposition).
    • Clarifies whether or not it should be a coroners case.

Referral to the coroner

  • Detailed list available at cremation.org.nz
  • Essentially anyone who dies:
    • An unnatural death (violent, suicide),
    • Or is in custody, or pregnant, at the time,
    • Or as a result of injury,
    • Or unexpectedly as a result of medical treatment or anaesthetic.
  • An exception applies for death by accident in the frail elderly. Patients over 70 years of age who die due of an injury that was primarily a result of their significant underlying medical condition e.g. Dementia -> NOF# -> death. But you must be certain there was no element of neglect or abuse that contributed, and no other indication for referral to the coroner. More detail on the exception here.

Sighting patients

  • It is reasonable to ask (or be asked) to sight a patient expected to die after hours.
  • This is primarily to benefit the family, as it will allow the body to be removed from the hospital. This is probably the most useful thing you can do, while on call, for the patient and their family.
  • If asked to sight a patient, you should be familiar with their condition, current treatment and sight them such that you can verify they are alive, and will then be able to identify them once they have died.
  • If you do not sight a patient alive, and are asked to complete the paperwork.
    • You must still verify the death and document this in the notes.
    • You should not do the paperwork if you have not seen the patient alive and the team (attending doctors) will be back within 24 hours of the death.
    • You should complete the paperwork if:
      • The team will not be back within 24 hours of the death, and
      • You are satisfied that referral to the coroner is not required.

Burial & Cremation Act 1964. Section 46B (3):
A doctor other than a doctor who attended the person during the illness may give a doctor’s certificate for the death if (and only if) satisfied that the person’s death was a natural consequence of the illness and that—
(a) the doctor who last attended the person during the illness is unavailable; or
(b) less than 24 hours has passed since the death, and the doctor who last attended the person during the illness is unlikely to be able to give a doctor’s certificate for the death within 24 hours after the death; or
(c) 24 hours or a longer period has passed since the death, and the doctor who last attended the person during the illness has not given a doctor’s certificate for the death.

Form B (cremation form)

  • Pecuniary interest
    • Might you receive anything in the will?
  • Ordinary medical attendant
    • This is generally the GP, and is very unlikely to be you!
  • Biomechanics aids
    • Is there something in this person that might blow up in a cremator and damage or people around it?
    • Also, if the patient has a communicable disease, have you written it on the death certificate? e.g. TB or hepatitis C.
  • Mode of death – layman’s explanation of how the death occurred.
    • Syncope (sudden event) e.g. collapse
    • Exhaustion e.g. respiratory compromise
    • Died in their sleep
    • Note there are 4 parts to this question on the form.
    • The rationale for this question to record how the patient died and who it was according to. If you didn’t witness the patient collapse and die, write down who did.