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Department of Health
Center for Health Statistics
Guideline
Revised – 2/23/17
Title:
Completion of Death Certificates
Number: CHS D-10
References:
RCW 70.58.170
Contact:
Daniel O’Neill, Senior Policy Analyst
Phone:
360-236-4311
Email:
Effective Date:
February 23, 2017
Approved By:
Christie Spice
The Department of Health provides this guideline for medical certifiers of death certificates.
Medical certifiers include allopathic and osteopathic physicians, physician assistants, advanced
registered nurse practitioners, chiropractors, coroners and medical examiners to follow when
completing death certificates.
The Department receives complaints that health care providers fail to complete death
certificates in a timely manner or fail to accurately list the cause of death on the death
certificate. The death certificate provides important information about the decedent and the
cause of death. Death certification errors are common and range from minor to severe.
Under RCW 70.58.170, a funeral director or person having the right to control the disposition
of human remains must present the death certificate to the medical certifier last in attendance
upon the deceased. The medical certifier then has two business days to certify the cause of
death according to his or her best knowledge and sign or electronically approve the certificate,
unless there is good cause for not doing so. The medical certifier should register cause and
manner of death information through the Washington State Electronic Death Reporting System
(EDRS). The EDRS facilitates timely registration of the death and rapid collection of cause and
manner of death information. The EDRS can be found at
https://fortress.wa.gov/doh/edrs/EDRS/.
The death certificate is a public legal document that deserves the certifier’s best effort to
ensure that it contains precise and accurate information. The death certificate serves different
medical, statistical, and legal functions. The death certificate has the vital function of providing
the synopsis of the cause and manner of death. It is in this scientific role that the medical
certifier has a responsibility to the general public’s health and advancement of medical
science.
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The cause and manner of death documented on a death certificates is coded to national and
World Health Organization standards using the International Classification of Diseases, 10th
Revision by the National Center for Health Statistics, a division of the Centers for Disease
Control and Prevention (CDC). These coded data, collected by all states, are used by CDC,
states, local health jurisdictions, and researchers to calculate life expectancy and mortality
rates by race, age, sex, educational attainment, veteran status, and geographic area. These
data are also used to determine which medical conditions receive research and development
funding, to set public health goals, monitor disease outbreaks, and to measure health status at
local, state, national, and international levels.
The completion of the death certificate also serves several different functions for the patient’s
family, loved ones, and estate. The death certificate is crucial as legal proof of death. From a
genealogical viewpoint, the death certificate serves as a historical reference to an individual,
recounting name, dates and places of birth and death, parent’s names, as well as other useful
demographic information. Providing accurate and timely cause and manner of death
information is a final act of care for the decedent, their family, and their loved ones.
Recommendation
Medical certifiers who complete death certificates should meet the standard of care in
completing all the information to the best of their ability. This must be done in a timely
manner. The medical certifier must certify the cause and manner of death if he or she
pronounced the death, were the first medical certifier to observe the decedent (e.g. died in
transport to the emergency department), were the primary care provider for the decedent and
recently treated the decedent, or is covering for another certifier who is unavailable. If a
medical certifier pronounces the death but does not have enough information to accurately
and precisely fill out the cause and manner of death, the medical certifier may consult with
another clinician or clinician’s records.
Deaths known or suspected of having been caused by injury must be reported to the medical
examiner or coroner, and the medical examiner or coroner will make the decision as to who
completes the cause and manner of death.
Guideline
The Department provides this guideline for practitioners completing death certificates.
Cause of Death
There are four lines or spaces provided to report the etiology of the cause of death. A
complete logical sequence should be reported that explains why the patient died. The
sequence may be an etiological or pathological sequence as well as a sequence in which an
earlier condition is believed to have prepared the way for a subsequent condition by damage
to tissues or impairment. The immediate cause of death should be on the top line and should
be the condition that occurred closest to the time of death. Do not list a mechanism of death,
such as cardio-pulmonary arrest, respiratory arrest, electromechanical dissociation, or asystole.
No other entry is needed if the immediate cause of death explains completely the chain of
events resulting in death. What is of most scientific interest is not the immediate cause of
death, but the specific disease condition or injury that set in motion the events leading to
death (i.e., the underlying cause of death). On the remaining three lines, sequentially list
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antecedent causes, if any, that lead to the immediate cause of death. Terminate the sequence
with the underlying cause of death and leave unused lines or spaces blank.
If the medical certifier has not seen the patient for a period of time he or she should apply
medical training, knowledge of medicine, available medical history, symptoms, diagnostic test
and autopsy results to render a medical opinion on the cause of death, and qualify the etiology
by use of words such as ‘probable’ or ‘presumed’ or, as a last resort, state the cause of death
as ‘unknown’.
Provide the best estimate of the interval between the presumed onset of each condition (not
the date of diagnosis) and death. The terms approximately or unknown may be used. Indicate
if the time interval is unknown.
Conditions that were present at the time of death and may have contributed to death but did
not result in the immediate cause of death should be listed in the box listed “Significant
Conditions Contributing to Death”. If two or more possible sequences resulted in death, report
the one that in your opinion most directly caused death in the cause of death section. Report
the other conditions in the “Significant Conditions Contributing to Death” box.
Cause of death information should be your best medical opinion
List only one condition per line or space in the cause of death section. If you need
more lines or spaces to describe the train of events leading to death, you may write
more than one condition per line if the conditions are separated by the words “due
to”
Avoid abbreviations
A condition can be listed as probable, possible or presumed even if it has not been
diagnosed
Elderly terms such as senescence, old age, and advanced age have little value for
public health or medical research. The decedent’s age is already listed on the death
certificate.
Infant prematurity should not be entered without explaining the etiology of the
prematurity
Surgery, Procedure, or Medication--report the condition that necessitated the
treatment
Always report an etiology for organ system failure such as congestive heart failure,
renal failure, or respiratory failure in the lines below it
Always report an etiology for cardiac arrest, cirrhosis, dementia, hemorrhage,
malnutrition, aspiration, inhalation, asphyxia, dehydration, hepatitis, pneumonia, or
sepsis
Report a primary site and/or histological type for neoplasms
If information with regard to specificity, etiology, pathology, or cause of death is
unknown, indicate explicitly that this is the case
If additional medical information or autopsy findings become available that would change the
cause of death originally reported, the original death certificate should be amended by the
medical certifier by filing an affidavit of correction with the Department of Health.
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Examples:
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Manner of Death
Choose from natural, homicide, suicide, accident, undetermined or pending. Refer all deaths
due to injury or poisoning to the medical examiner or coroner. Complete the cause and
manner of death if the medical examiner or coroner does not accept the case. Pending is used
if you are waiting on toxicology or other test results. The record should be amended by the
medical certifier filing an Affidavit of Correction with the Department of Health once the results
are received.
Time of death (Hour of death)
The exact time should be entered, if known, using the 24 hour clock.
Checkboxes
1.
Autopsy
Yes or no
2. Autopsy results available to complete the cause of death
Yes or no
3.
Tobacco
Yes, probably, no or unknown if to the best of your knowledge use of tobacco or
exposure to tobacco contributed to death.
4.
Pregnancy
This must be answered if the decedent was female and ages 10 to 55. The check
boxes include responses for women who are pregnant at the time of death as well
as options for women who were pregnant up to one year before their death.
Pregnancy includes live births, fetal deaths, and abortions.
Injury Information
Most injury deaths are accepted for cause of death certification by the medical examiner or
coroner. Occasionally, especially for deaths where a fall in someone elderly is on the causal
pathway, a medical certifier will fill out the cause and manner of death. In the instance where
this occurs, the injury information must be filled out.
1.
Date of injury
Enter the act the actual date, if known.
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2.
Time of injury (hour of injury)
Enter the exact time, if known, using the 24 hour clock.
3.
Place of injury.
Enter the general type of place where the injury occurred. Do not enter firm or
organization names.
4.
Injury at work?
Enter yes if injury occurred at work.
5.
Location of Injury
Enter the complete address including ZIP Code. Fill in as many of the items as
known.
6.
Describe how the injury occurred
Enter in narrative form, a brief description of how the injury occurred. Explain
the circumstances or cause of the injury. If the injury is a fall, describe how the
fall occurred, if the fall involved an object (ladder, stairs, wheelchair, furniture,
bed), other person (supported or carried by another person), or if the fall
occurred from tripping or falling from the same level (standing or sitting to the
floor or from the toilet to the floor) or from another level (hole or well).
Name and Title of the Attending Physician (if other than Certifier)
This is optional and would be the attending physician of record that is different than the
medical certifier filling out the death certificate. It is helpful to have this name if the certifier is
a medical resident and may not be available to answer questions about the cause of death
information.
The Department of Health provides this guideline for medical certifiers to follow when
completing death certificates.
References:
Medical Quality Assurance Commission. (2011, September). Death Certificate Rules Revisited.
Volume 1, Fall. p. 10. Retrieved from
www.doh.wa.gov/Portals/1/Documents/Pubs/658004.pdf.
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“Physicians Handbook on Medical Certification of Death.” U.S. Department of Human and
health Services, Centers for Disease Control and Prevention, National Center for Health
Statistics, 2003 Revision, page 1
