Medical Transcription: Death Summary
The Death Summary is part of the Big Four: the family of reports that comprise the core of medical transcription work. In transcribing the report, you step through each section in detail, including section headings, formatting, and organization.
When a patient dies, the Discharge Summary becomes a Death Summary. Transcribing a Death Summary can be somewhat heart wrenching, especially when it’s clearly sudden and unexpected or involves a child. Often the dictator’s tone of voice will reveal feelings of regret, although in other cases the doctor is very matter of fact about it. Fortunately, Death Summaries are one of the least common report types.
A Death Summary contains a subset of the normal Discharge Summary headings. Key differences include the following:
Discharge Date will be replaced by Date Expired or Date of Death.
Discharge Diagnoses will be replaced by Final Diagnoses.
Cause of Death may be dictated as an explicit heading.
It’s common for a death summary to contain only Final Diagnoses and Hospital Course sections. Occasionally, the dictator will give a narrative description with no headings at all.
If you encounter a death summary that particularly upsets you, don’t hesitate to e-mail or call a fellow medical transcriptionists. You can’t reveal patient specifics due to privacy concerns, but you can give a general description of the circumstances. Often just sharing the information will help you feel better.