Date of Birth of Deceased: {{patient.birthdate | bahmniDate}}    Date of Admission: {{visitSummary.admissionDetails.date | bahmniDate}}    Ward No: {{bedDetails.bedNumber}}
Date and Time Of Death: {{dateAndTimeOfDeath | bahmniDateTime}}        NID No:{{DeceasedNID}} ({{nidOf}})        NID No:{{SpouseNID}} ({{nidOf}})        NID No:{{ParentsNID}} ({{ParentsNID}})
Frame A: Medical data: Part 1 and 2
1
Report disease or condition directly leading to death on line a

Report chain of events in due to order (if applicable)

State the underlying cause on the lowest used line


 
a
b
c
d
Cause of death
{{lineA.value}}
{{applicableB.value}}
{{lineC.value}}
{{dueD.value}}
Time interval from onset to death
{{timeA.value| bahmniDateTime}}
{{timeB.value| bahmniDateTime}}
{{timeC.value| bahmniDateTime}}
{{timeD.value| bahmniDateTime}}
2
Other significant conditions contributing to death
(time intervals can be included in brackets after the condition)
{{otherSignificantCondition.value}}
Frame B: Other medical data
Was Surgery Performed Within The last four Week {{frameBSurgeryPerformedLastWeek}}
If Yes Please Specify Date of Surgery {{frameBSpecifyDate| bahmniDateTime}}
If Yes Please Specify Reason for Surgery Disease or Condition {{frameBSpecifyReason}}
Was an Autopsy Requested? {{frameBAutopsyRequested}}
If Yes, were the Findings used in the Certification {{frameBCertification}}
Manner of Death {{mannerOfDeath}}
If external cause or poisoning: {{externalPoisoning}}
Date of Injury {{dateOfInjury | bahmniDate}}
Please describe how external cause occurred
(If poisoning please specify poisoning agent)
{{describePoisoning}}
Place of Occurrence of the external cause {{placeOfOccurrence}}
Other Place (Please Specify): {{otherPlace}}
Fetal or infant Death
Multiple Pregnancy {{multiplePregnancy}}
Stillborn? {{stillBorn}}
If death within 24h specify number of hours survived {{numberOfHour}}
Birth weight (in grams) {{birthWeight}}
Number of completed weeks of pregnancy {{weeksOfPregnancy}}
Age of mother (years) {{ageOfMother}}
If death was perinatal, please state conditions of mother that affected the fetus and newborn {{newBorn}}
For women of reproductive age
{{data.concept.shortName}} {{data.value.shortName}}