Page 1 - covid19_M

Mortality review for COVID-19 cases

Hospital name Region

Hospital type Gov. □ Priv. □ Reviewer name

Patient profile
Patient name Nationality
Medical record Age Male □ Female □
number
Location ICU □
Consultant at the time
of death (department/unit)
of death Ward □

General details
□ Community
If referred, □ Other gov. hospital
Admitted from: □ Referral
from where?
□ COVID-19 Isolation □ Private hospital …………………………
/ /2020 □ Am
Date of admission OR Time of admission :
/ /1441 □ Pm
/ /2020 □ Am
Date of death OR Time of death :
/ /1441 □ Pm

High-risk conditions
Select all applicable

□ Elderly (aged 65 years or more) □ Hypertension

□ Underlying end organ dysfunction □ A history of cardiovascular disease

□ Diabetes □ A history of pulmonary disease

□ Is immunocompromised □ Cancer

□ Obesity or severe obesity (BMI >= 30) □ Pregnancy

Complications (outcomes)
Select all applicable

□ Sepsis □ Acute kidney injury

□ Septic shock □ Hepatotoxicity

□ Bacterial pneumonia □ Gastrointestinal perforation

□ Acute respiratory distress syndrome (ARDS) □ Multi-organ failure

□ Arrhythmia □ Other:………………………….

1 Mortality review committee for COVID 19 19 June 2020