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UNIT STAFF COMPLETE AND PROVIDE TO BEREAVEMENT COORDINATOR Bereavement Coordinator Name _________________
 

Summary: UNIT STAFF COMPLETE AND PROVIDE TO BEREAVEMENT COORDINATOR
Bereavement Coordinator Name _________________
Unit _________________________
NAME______________
(Sticker) MRN_____________ SEX_____
ADMIT DATE_____________
BEREAVEMENT FOLLOW-UP CHECKLIST
Patient Information: Primary Language Spoken________________
Patient's Date of Birth___________ Marital Status []Single []Married []Widowed/Divorced
Date and cause of death _________________________________________________
Patient Care Unit/location where death occurred______________________________
RN and MDs caring for patient at the time of death____________________________
Other Patient Care Units/staff involved during dying process
_____________________________________________________________________
Chaplain Involved:[]Yes []No / Autopsy granted: []Yes []No / Organ Donation:[]Yes []No
(Page Chaplain on call with any questions or concerns)
Family Information:
Was family present at time of death []Yes []No
Describe any blessings/issues/concerns/family reaction:
_______________________________________________________________________________

  

Source: Acton, Scott - Department of Electrical and Computer Engineering, University of Virginia

 

Collections: Computer Technologies and Information Sciences