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Midega Hospital Death Report Template

This document is a death report from Midega Primary Hospital, detailing the deceased's information, including name, age, sex, admission and death dates, and causes of death. It also includes management and treatment given, as well as additional information regarding the deceased's pregnancy status if applicable. The report is to be filled out by a medical professional and approved by the medical director.

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Ibsa Abdo
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264 views1 page

Midega Hospital Death Report Template

This document is a death report from Midega Primary Hospital, detailing the deceased's information, including name, age, sex, admission and death dates, and causes of death. It also includes management and treatment given, as well as additional information regarding the deceased's pregnancy status if applicable. The report is to be filled out by a medical professional and approved by the medical director.

Uploaded by

Ibsa Abdo
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

MIDEGA PRIMARY HOSPITAL

DEATH REPORT

Health Facility: Region: City:

Deceased Name: Age (Year): Sex:

F M

Date of admission: Date / Month / Year Time Hrs : Min

Date of death : Date / Month / Year Time Hrs : Min

Cause Of Death Approximate Interval Between Onset And Death


I. Disease or condition leading to death*: -
Due to (as consequence of)
a)

b)
Antecedent cause: Morbid conditions, if any, giving rise to the above cause, stating:
- Due to (as a consequence of)
c)

d)
* This does not mean the mode of dying, e.g. heart failure, respiratory failure. it means the disease, injury or complication that caused death.
II. Other significant conditions contributing to the death, but not related to the disease or condition causing it

Management/Treatment given :

Consider Collecting the following Information


If the deceased is a female, was she:

Not pregnant
Pregnant at the time of death (Approximate gestation age ______ (WKS))
During labour ( stage of labour ______________)
Unknown pregnancy status

. If the deceased is a newborn:


 Still birth  Death after birth Weight: . . . . . . . . . g  Not Known

Reported by (Dr./ Mr/Ms):_________________________________________ Profession:___________________________

Signature: _________________________ Date:_______/______/___________

Approved by: Medical director:

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