SESSION 1: OVERVIEW

Civil Registration and Vital Statistics might be a case of garbage in and

(CRVS) garbage out.
● Mandates basic and compulsory ● The Philippine Statistics AUthority
registration of all vital evens & (PSA) manages the CRVS and
changes in civil status. reports infectious diseases such as
● Continuous, permanent, compulsory, measles, pneumonia, TB and
and universal recording of the HIV/AIDS as major causes of death.
occurrence and characteristics of ● Noncommunicable diseases such as
vital events pertaining to a cardiovascular diseases, diabetes
population. and cancer are also now part of the
● Primary source of public health picture.
information on birth and cause of ● Mortality/Morbidity data can be
death. organized and compared according
● Valuable measure in assessing the to time, age, sex and geographic
nation’s health status of vital events. locations.
Republic Act 7160 (Local Government ● Average death for Filipino males is
Code) 64 yrs old.
● Civil Registrar of the city/municipal is ● Illustration
in-charge of collecting these data on ○ Blue: noncommunicable
vital events upon certification and ○ Orange: communicable
reporting by the health professional, ○ Green: external events
facilities, or communities where the ● Top leading cause of death for 15-64
events occured. Filipino Males:
Importance of CRVS ○ Violence (13.05%)
● Vital Statistics: product of an ○ IHD (13.03%)
administrative and legal process ● More than half of the deaths are
which is civil registration. caused by NCDs.
○ Universal Uses of Morbidity and Mortality Data
○ Continuous ● Setting priorities in health policies.
○ Permanent ● Identification of health inequalities.
○ Compulsory ● Resource allocation.
○ Very cost-effective ● Assessment of health system
○ Available performance.
○ Very granular ● Awareness of emerging health
● The gold standard of health challenges.
information because the data are Common Problems in Vital Statistics
from actual events and not estimates ● Completeness
nor projections. ○ Not all births and deaths are
● Data must be of good quality, registered.
accurate, relevant, complete and ● Quality
timely to be useful. Otherwise it ○ Poor quality of death
certification.
 ● Timeliness signifies problem in the COD
○ Poor timeliness. reporting here in the
○ 2010 data made publicly Philippines
available only in 2014. ○ Chronic lower respiratory
■ Government was diseases
making decisions ○ Diabetes mellitus
based on old ○ Certain conditions originating
information. in the perinatal period
Coverage of Civil Registration ● NOTE: In 2016, “ill-defined and
● Births are registered more than unknown causes of mortality” is no
deaths because DC requires longer included in the Top 10
physicians while BC can be Leading COD in the Philippines.
accomplished by physicians, nurses, ● Incomplete details have been
midwives, traditional hilots or one of observed in infectious diseases,
the parents. cancer, maternal deaths and
● People put more value on birth accidents.
certificates. ● Ill-defined causes of death are
○ It is a requirement for reported in almost all of the groups
schools, passports, marriage, and conditions and may be due to
etc. the urgency of the situation that is,
● Only 33% of the DC are medically for the immediate release of
attended. thedeath certificates to allow the
● ⅔ of Filipinos who die at home are burial of the deceased or the lack of
not medically attended to. appreciation for filling it up correctly.
3 Most Common Problems with COD
Data
● Poor quality, high proportion of Other problems:
ill-defined deaths. ● Low emphasis on the importance of
● Incomplete details regarding deaths death certificates.
from infections, neoplasm, accident, ○ Lack of quality checks in the
etc. civil registration process (lack
● Confusion between immediate and of standards in quality
underlying COD. assurance, training of
10 Leading Causes of Death coders, doctors, and
● 2004 registrars)
○ Diseases of the heart ● Weak infrastractures.
○ Diseases of the vascular ○ Poor communication channel
system or collaboration between the
○ Malignant neoplasms different authorities
○ Accidents responsible.
○ Pneumonia ● Low utilization of vital statistics data.
○ Tuberculosis Department of Health
○ Ill-defined and unknown
causes of mortality →
 ● Agency mandated to formulate
health policies and programs to
benefit all FIlipinos.
● The basis for these policies and
programs are the different vital
statistics.
Medical Certificate on the COD
● Is the critical source of mortality
census for the country.
● Nonregistration of death and
erroneous information in the
registration of deaths may present
problems for planning health
services especially among
marginalized and poverty-affected
sectors.
The Way Forward
● The MCCOD improvement can only
be realized with a strong national
partnership among doctors on
learning and correct practices.
● Better data, better decisions,
healthier Filipinos
● Make strategic alliances with the
adaceme, PRC and CHED.
● Institutionalize the MCCOD
curriculum in all medical schools.
● Develop a standard MCCOD module
which is sustainable.
Key Areas to Strengthen
● Complete and accurate registration
of births and deaths.
● Correct death certification (i.e.,
ICD-10 compliance, etc)
● Diagnosis causes of medically
unattended deaths.
SESSION 2: CRVS & HEALTH INFORMATION SYSTEM, DATA QUALITY AND STANDARD
DATA

Civil Registration and Vital Statistics

System
● 2015-2024 Medical Record
○ Philippine Decade of Civil ● Has data that is aggregated
Registration and Vital ● Analyzed using epidemiological and
Statistics social science tools at the rural
● Provides all FIlipinos the evidence health unit or the private clinic such
needed to obtain legal identity, as a dialysis center or your hospital
nationality, and the recognition of all ● These data is submitted by the rural
rights. health clinics/dialysis center/hospital
● Managed by the Philippine Statistics to the Department of Health who
Authority. analyzes the data nationwide and
● Records vital events adjust to improve plants and
Vital Events fundings for our country’s health
● Birth priorities.
● Death ● RHU/clinics/etc submits relevant
● Marriage/Marital Dissolution individual data to the PhilHealth so
Birth Certificates that the facilities can claim funding
● Evidence of legal identity of the for services rendered to the patients.
Filipino citizen ● Health Sector → Local Civil Registry
● Formalizes the recognition of Offices & LGU → PSA Provincial
entitlements and rights afforded to Offices → PSA Regional Offices →
all: PSA → Civil REgistration Service →
○ Life and health Vital Statistics Division
○ Education ● Doctors should demand good quality
○ To be known as Filipino data.
entitled to all these services ● Mortality data is challenged with
and care and to allow one to poor data quality:
contribute back to the ○ Ilegibility
country ○ Inaccuracy
Death Certificates ○ Incompleteness
● ends these rights ○ Untimeliness
CRVS System ○ Inaccessibility
● Evidence for vital events such as Understanding Data Quality
birth and death ● Data
● A doctor is the only one authorized ○ A "packet of truth"
to declare that one is born or died ○ A representation of facts or
● CRVS system and Health concepts or instructions in a
Information System are linked by the formalized manner, suitable
virtue of the physician. for communication,
 interpretation or processing ○ Reliable: consistent and
by manual or electronic understandable
means. ○ Complete: required elements
○ An element of data is an are present
item, idea, or raw fact. ○ Legible: readable and
● Healthcare Data comprehensible
○ Item(s)/ fact(s) about an ○ Current and Timely
individual or group of patients ○ Accessible
○ Examples of healthcare data: ○ Meaningful and Useful
■ Productive cough DIKA Lifecycle
■ 30% weight loss in ● Metadata/Data → Information →
last 4 weeks Knowledge → Action
■ Fever Data. Quality Dimension
● Information
○ Meaningful data, understood
Are all data vatu at wttfen
PM m dorr
specified t>y the business">

in a specific context

DATA INFORMATION Are the relationships

between entities and
attributes consistent "?

Collection of facts How facts are

understood in
context ii present

KATIPUNAN
Unorganized Structured and K-Kumpleto
organized
T-Tama
Not typically useful Useful on its own P-Napapanahon
on its own N-Nababasa
N-Nagagamit
Generally includes Depends on data
the raw forms of
numbers,
statements and
characters

● Healthcare data is intensive.

Quality Data
● fact
● intended or defined by the source
● objective and unbiased
● comply with known standards
● must be:
○ Accurate and valid: reflects
the event as it actually
happened
SESSION 3: ICD - 10
International Classification of Diseases
● International standard for defining and reporting diseases and health conditions
● Defines the universe of diseases, disorders, injuries and other related health conditions
which are listed in a comprehensive way
● Designed to promote international comparability in the collection, processing,
classification, and presentation of mortality statistics
Significance and Uses
● Organizes information into standard groupings of diseases, which allows for:
○ easy storage, retrieval and analysis of health information for evidence-based
decision-making
○ sharing and comparing health information among hospitals, regions, settings and
countries
○ data comparisons in the same location across different time periods
● Biggest strength lies on its impact on mortality statistics:
○ standardized reporting of cause of death since these conditions are coded using
a classification structure
○ coded data are analyzed, used nationally and internationally regardless of
language used to complete the certificate
Impact on Medicine and Public Health
● specifically on:
○ Clinical dx & mgt
○ Research
○ Epidemiology
○ Statistics and surveillance of incidence and prevalence of diseases (emerging
and re-emerging)
○ Resource allocation (health insurance, reimbursements)
○ Safety & quality guidelines
Note:
● ICD-10 coding is a 5-day Course meant for Medical Records Officers of Hospitals/
Medical Centers, Local Government Health Offices and statisticians of the Philippine
Statistics Authority.
● By January 01, 2022 all member states of the WHO will use ICD-11 as its official
reporting system.
● Doctors MUST use their knowledge of their patient and the pathophysiology of the
disease conditions in order to correctly certify death.
● Good clinical diagnosis of cause of death is a prerequisite to correct tagging to the
appropriate ICD code by the PSA.

Standards for Medical Terminology and Coding

Concept: Ideas
Terminology: set of words that conjure those ideas
Code: a representation applied to a term so that it can be more easily processed
Classification: arrangements of all elements of a domain, into groups according to an
established criteria

Definition Examples

Code A representation applied to a term so that it can Read code for asthma is
be more readily processed. H 33
Classification Arrangements of all elements of a domain , into International
groups according to established criteria. Classification of Disease
( ICD)

Terminology Language labels attached to a concept - all Read Clinical Terms

terms of a professional domain. version 3, CTv3
Nomenclature Naming things: in a nomenclature, codes are Systematized
assigned to medical concepts, and medical Nomenclature of
concepts can be combined according to specific Medicine ( SNOMED )
rules to form more complex concepts. This
leads to a large number of possible code
combinations.

Who uses terminology and who uses code?

● The clinician uses terminology to express their thoughts and observations of the
clinical encounter.
○ "Three day history of epigastric pain later transferring to the right lower quadrant."
○ "Icteric sclerae"
○ "Oriented to the three spheres: person place, and time"
● The coder uses code to classify cases.
○ C09.0 Malignant neoplasm of the submandibular gland
○ C07 Malignant neoplasm of the parotid gland
What is the difference between terminology and classification?
● Use terminology to describe, in the best detail possible, the clinical picture (for patient
care)
● Use code to generalize the case of the patient into a classification for planning and
administrative purposes (for public health)
The sequence is important - first use detailed expressive terminology for patient care
● The patient's case should be documented to the best possible detail in the medical chart
● Coding will follow
● DO NOT CODE UNTIL THE DETAILED CLINICAL DOCUMENTATION HAS BEEN
DONE
○ You will lose vital information needed for the case.
Finally, use standards
● Clinical terminology: Standardized Nomenclature for Medicine (SNOMED.org)
● CD-10: for classification of diseases at par with other countries
● Current Procedural Terminology (CPT): for medical, surgical, and diagnostic
procedures and services
● International Classification of Primary Care (ICPC)
Anatomy of ICD-10
Case

A 68-year old woman accidentally slipped on the bathroom floor and fell on her right arm,
acquiring a torus fracture of the forearm, Iower end of right radius.
ICD-11
● "is a substantial improvement on ICD-10. 55,000 unique codes for injuries, diseases,
and causes of death are included, compared with 14,400 for ICD-10. A wide consultation
led to 10,000 proposals for change.
ICD-10 Characters
● Characters 1-3 = Category
● Characters 4-7 = Etiology, Anatomic Site, or Other Clinical Detail
● Character 7 = Extension
Example
● 52 Fracture of Forearm
● 52.5 Fracture of Lower End of Radius
● 52.52 Torus Fracture of Lower End of Radius
● 52.521 Torus Fracture of Lower End of Right Radius
● 52.521A- Torus Fracture of Lower End of Right Radius, Initial Encounter for Closed
Fracture

Session 3: ICD-10

1893 1909 1929 1948 1975 1990 2019

ICD-1 ICD- 2 ICD- 4 ICD-6 ICD- 9 ICD- 11

International International Categories International Narrative Sexual Health
List of List of Causes based on Classification descriptions of ICD- 10 Traditional
Causes of of Sickness etiology of Diseases, Mental & Medicine
Death and Death Injuries and Behavioral Stroke, HIV
Causes of disorders
Death

ICD - 11
● Functions in an electric environment
○ Digital product
○ Link with terminologies (e.g, SNOMED) and other classifications
○ Support electronic health records and information systems
● Multipurpose and coherent classifications
○ Mortality, morbidity, primary care, clinical care, research, public health
○ Consistency and interoperability across different uses
○ Better integration with other Disease Classifications
○ International multilingual reference standard for scientific comparability
 ● Released on June 2018 to allow member states for eventual implementations

SESSION 3: Death Registration: Legal Mandates, Rules and Procedures

What is Death?
● Permanent disappearance of all evidence of life or vital functions at any time after live
birth
● Results when all resuscitation measures fail to revive the person

Possible Signs of Death

● Unconscious
● Failing to respond to outside stimulation
● Heart rate and respiratory rate are zero
● Blood pressure reading is zero

Death is determined when there is permanent loss of capacity for consciousness and loss of all
brainstem functions, as a consequence of permanent cessation of circulation or catastrophic
brain injury.

What is Fetal Death?

● Death prior to the complete expulsion or extraction from its mother of a product of
conception regardless of the duration of pregnancy
● After separation from mother, fetus does not breath nor doesn’t show any evidence of
life such as beating of the heart, umbilical cord pulsation or definite movement of
voluntary muscles
● Fetal death should be certified if:
○ 20 weeks or more AOG
○ More than 500 grams
● A fetus <7 mos and dies within 24 hours after delivery is not deemed born.

Vital events → births, deaths (included tong sa baba)

Changes in civil status → marriage, separation, adoption

Act No. 3753 Civil Registry Law

● Mandates registration of all facts and acts concerning the person's civil status, from birth
to death, including the changes in civil status.
● Approved in Nov 1930
● Made effective in Feb 1931
● The law requires the continuous, permanent, compulsory and universal recording of the
population's vital events.
● Sec. 6: Death Certificate and Register
 ○ No human body shall be buried unless the proper death certificate has been
presented and recorded in the office of the local civil registrar.

PD 856: Code of Sanitation of the Phil., 1975

● No remains shall be buried without a death certificate issued by the attending physician.
● If there is no physician, the death certificate can be issued by the Mayor of the area.
● Death certificates shall be forwarded to the Local Health Officer within 48 hours after
the death of the person

DOH Mandates
● Circular on the Cause-of-Death Flyer (No. 2012-0231) → elaborates on the use of
specific ICD-10 codes and refrain from using ill-defined or garbage codes
● Memorandum on Filling out Time Intervals (No. 2016-0286) → reminds all certifiers that
they should fill out the time interval in the medical certificate of death
● Circular on Guidance forCertifying COVID-19 Deaths → guides physicians in certifying
COVID as COD

DOH Administrative Order No. 2020-0008

Rules on Medical Certification of Cause of Death (MCCOD)
● Concur with described and clarified rules on MCCOD
● Adhere to standard procedure on the following:
○ reporting certifying and reviewing causes of death
○ referring cases of death that warrant medico-legal investigation
● Clarify roles and responsibilities of the different key actors
● Establish the use of verbal autopsy in specific cases for cause of death determination
● Monitor compliance and violations of existing CRVS laws and regulations

Legal Mandates
● The physician certifying death is attesting to the best of his knowledge that the person
named died from the causes of death and in the circumstance stated
● The reported causes and circumstance of death represent the physician's best medical
opinion

Local Health Officer must:

● Review all death certificates if:
○ Complete
○ Correct
○ ICD-10 compliant
 ○ Devoid of mechanical errors
● If the certificate of death needs improvement, LHO shall return the death certificate to
the Certifier

Article 412 Civil Code of the Philippines

● Medical Certificate entries must be correct and complete before registration since there
is a prohibition against change or correction of entries without judicial order.

Falsified information can make you liable and you can lose your license as a physician.

Specific Rules on Cause of Death Certification by Type of Death

Fetal Deaths
● Certificate of Fetal Death (COFD) shall be accomplished within the reglementary period
of 30 days from time of death.

Deaths in Emergency Room/Emergency Department

● Emergency Room Deaths
○ Deaths that occurred or were brought to the emergency room
● For all cases of ER deaths, the ER Officer shall certify death except for Medico-Legal
deaths.
● Within 30 days

Death in an Ambulance
● Certifiers of Death:
○ Last attending physician during patient's transport → accompanying/attending
physician
○ Administrator of the receiving hospital

Dead-on-arrival
● Certifiers of Death:
○ ER Officers shall conduct a verbal autopsy to certify the cause of death.

Deaths in Moving Conveyances

● Reporter of Death:
○ Driver/ship captain/pilot of moving conveyances
○ No survivors → owner of moving conveyances
● Certifier of Death
○ Local health officer

Deaths in Mass Casualty Incidents where body is not identified

 ● Reporter of Death:
○ Nearest Kin
○ Person with Knowledge
● Certifier of Death
○ Local health officer*
● with affidavit by two disinterested persons

Deaths Requiring Medico-legal Investigation

● Medico-legal cases:
a. Deaths due to injuries where the circumstances suggest commission of an offense by somebody
b. Suspected or evident criminal abortion, poisoning, or intoxication
c. Cases referred from PNP/NBl or patients under police custody
d. Undiagnosed coma/unconsciousness
e. Death due to decapitation
f. Death where the deceased is in an advanced state of decomposition
g. Cases brought dead with improbable or inconsistent medical history creating suspicion of an
offense
h. Cases when Verbal Autopsy results are inconclusive
i. Any other case not falling under the above categories but has legal implications.

How to Certify Medico-legal cases

1. Report to appropriate police station or precinct
2. Medico-legal officer shall obtain consent for autopsy
a. If no Medico-legal officer is available in the precinct and government health facility, local health
officers shall conduct medico-legal examination or autopsy.
3. Death Certificate shall be transmitted within 48 hours for local health officers review
4. If the cause of death is still unknown after 48 hours, the medico-legal officer may write "pending
investigation" on the MCCOD portion.

Dismembered Body Part

● Civil Registry Law Sec. 6
○ Body parts removed by the surgery, accident, etc. → not considered as the death of a person.
○ NOT be registered as death; but these body parts should also be buried

Certifying Dismembered Body Parts

● The surgical pathology report signed and issued by the pathologist shall serve as the Certificate of
Dismembered Body Part which may be used for burial purposes or proper disposal.
● Issuing a Certificate of Death by the attending physician for the dismembered body part is not necessary.
● No registration
● Used for burial purposes
● Issued by pathologist or surgeon

Republic Act 7160

● Civil Registration is a function of the local government registrar but is under the technical supervision of the
Civil Registrar General of the Philippine Statistical Authority.

RA 106225
● The Phil. Statistical Act Article 6(e) mandates the Philippine Statistics Authority to carry out, enforce and
administer civil registration functions in the country.

Death Registration Process (In-facility)

 1. Death 2. Determine if death requires 3. Certify the
medico- legal examination cause of death
(attending physician) ( Attendant at
Death)

NO
Proceed to
#3
YES
Conduct
medico-legal
examination
V (medico legal
officer)

3. Certify the 4. Report the death 5. Review 6. Transmit death

cause of death by transmitting the death certificate certificate within
( Attendant at death certificate (Local Health 30 days (Local
Death) within 48 hours. Officer ) Health Officer )
( Attendant at Death)

within 7. Register death

48
hours
(Local Civil Registrar )

Death Registration Process (Out-of-facility)

.
% last attending
physician
2 . Determine if death requires
medico -legal examination
1 Death
J (attending physician, LHO)

Conduct
NO
Proceed to
Ш
medico - legal #3
examination
(medico legal

»Ш

3. Certify the 4. Report the death 6. Transmit death

cause of death by transmitting the certificate within
(death attendant: death certificate 30 days (Local
last attending within 48 hours. Health Officer )
physician, LHO, ( Attendant at Death)
medico legal
officer)
within
48
hours

Death Registration Process

● Death should be recorded within 2 days after its occurrence
● Muslims and indigenous people can report within 48 hours after burial. This is this is to honor and preserve
cultural practices on death and the immediate burial of the dead
● In these cases the muslim or ip form should be attached to the certificate of death.
Place of Registration: Local
 ● City or municipality where the event occurred except in circumstances where the place of death is not
ascertained

Place of Registration: Abroad

● Philippine Foreign Service Establishment (PFSE) of the place of residence of the party concerned or where
the vital event occurred, or where none is located, PFSE in the nearest country.

Delayed Registration
● Received by Local Civil Registrar AFTER the 30-day registration period
● For deaths attended by a physician (in-facility or out-of-facility), registration follows the usual process
● For Medically unattended deaths:
○ family of deceased should provide affidavit for delayed registration, report to Local Health Officer
○ Local Health Officer certify death by verbal autopsy
○ transmit Certificate of Death to Local Civil Registrar

Affidavit for Delayed Registration

● Executed by:
○ Nearest relative
○ Any person having legal charge of the deceased when still alive
● Shall state the following:
○ Name of the deceased
○ Facts surrounding his/her death
○ Date and place of burial or cremation
○ Circumstances why the death was not reported for registration

When can death registration be denied?

● Insufficient information
● Absence of the following essential entries:
○ Identity of the deceased, and
○ Cause of death

Uses of Certificate of Death

● Settlement of estate
● Claim of benefits, pensions, insurance, or tax exemption
● Inform/alert relatives of disease conditions that they are at risk and possibly prevent
● Remarriage purposes
● Designation of guardian/parent for minor
● Serve administrative purposes, specifically, in the clearing of files like electoral rolls and tax registers
● For policy and legislative development

Public Health Uses

● Provide data on existing infectious diseases, epidemics
● Mortality surveillance
● Basis for designing programs and strategies for public safety, accident prevention, and crime eradication.
● Epidemiologic research

Key Points
● Legal Mandates:
○ Civil Registry Law (RA 3753)
○ Philippine Statistical Act (RA 10625)
○ Local Government Code (RA 7160)
○ Philippine Code of Sanitation (PD 856)
○ Article 412 Civil Code of the Philippines
○ Rules on Medical Certification of Cause of Death (DOH AO 2020-0008)
 DEATH Rl a

.
2 Medico -legal 3. Certifying Death 4 . Review Death
f examination, \ (last attending Certificate (Local
if needed I
physician, local Health Officer )
(Medico-legal health officer,
officer)
J medicolegal
officer )

.
5 Register Death
(Local Civil
Registrar

● USES OF DEATH CERTIFICATE

○ prima facie evidence for legal purposes and benefits claim
○ source of information on existing infectious diseases and epidemics immediate control measures
○ source of information, basis for designing programs and
● strategies for public safety, accident prevention, and crime
● eradication.
SESSION 5: Understanding Medical Certification of Death and Its Principles

Death
● Permanent disappearance of all evidence of life or all vital functions
● Postnatal cessation of all vital functions without capability of resuscitation

Fetal Death
● Death prior to complete expulsion of a product of conception irrespective of the period of pregnancy.
● No beating of heart, pulsation of umbilical cord, definite movements of voluntary muscles after separation
from mother.

Maternal Death
● Death of a woman while pregnant
● Death within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy
● Death from any cause related to or aggravated by the pregnancy or its management

Principles on Death Certification

● There are good ways, better ways, and inadequate or incomplete ways of writing the cause-of-death
statements.

Municipal form no. 103 → CERTIFICATE OF DEATH

Medical Certificate portion of the COD

● Authorized personnel only!
○ Entries MUST be filled in by the ATTENDING MEDICAL DOCTOR (MD)
● Affix signature!
○ As certifier of death, attending MD must affix his/her signature in item #22

Review of the COD

● Done by the Local Health Officer
○ Affixes signature after thorough evaluation of the entire certificate
○ Signs twice if the deceased died without medical attendance:
■ As the certifier
■ As the reviewer

Death Registration
The COD which must be reported in the Medical Certificate refers to all diseases, morbid conditions, or
injuries that either result in or contribute to death. The circumstances of any accidents or violence which
produce such injuries must also be reported.

Certification of Death
● Determine whether:
○ Death is reportable or not.
○ Another physician is more qualified to complete the certificate.
● A physician who previously saw and treated a patient who died outside the hospital is more qualified to
certify the death.

Physicians are expected to use:

● Medical Training
● Knowledge of Medicine
● History & Physical Exam Findings
● Diagnostic Tests
● Autopsy Report

Seldom is there a single"correct" way of certifying death.

There are erroneous, good,and better ways of writing the cause/s of death.

Medical certificate portion

● Reported in causal order
● Once cause per line
MEDICAL CERTIFICATE
( For ages 0 to 7 days, accomplish items 14 -19a at the back )
19b. CAUSES OF DEATH (if the deceased is aged 8 days and over) Interval Between Onset and Death

I Immediate cause

Antecedent cause : b

Underlying cause : c.

II Other significant conditions contnbuting to death

● Immediate & most recent physiologic event causing death reported on 1st line

Underlying COD
● The disease or injury which initiated the train of morbid events leading to death.
● The circumstances of the event or violence which produced the fatal injury.
● If only one cause of death is reported, it must be the Underlying Cause.
● The MOST IMPORTANT entry in the Certificate of Death.
● Basis for preventive public health programs.
● Basis for Mortality Statistics.
● Underlying Cause of Death should be ICD-compliant.

Immediate COD
● Most recent condition before death, directly leads to death.
● Written on the top line of the Certificate of Death

Antecedent COD
● Other intervening causes of death
● Written on the middle line of the Certificate of Death
● Can have one or more antecedent COD
 ● Occur between the immediate and underlying causes of death

INTERVAL between onset and death

● Unknown" or approximate" is acceptable if such is the case
● Often estimated
● Underlying COD
○ Occurred earliest or FIRST
○ Time between onset of the underlying COD and time of death
○ Longest interval
● Antecedent COD
○ Occurs after the underlying but before immediate causes
○ Time between onset of the antecedent COD and time of death
○ Period within the intervals of underlying and immediate COD
● Immediate COD
○ LAST condition that directly resulted to death
○ Time between onset of the immediate COD and time of death
○ Shortest inte

Case 1
A 73-year old woman with known Alzheimer's disease for about 15 years had recurrent bouts of aspiration
pneumonia and finally died in a hospital after a few weeks.
Causes of Death
Interval From
Onset to Death
a Aspiration Pneumonia Weeks
Approximately
isease 1 5 уpar »;
due to/ secondary to ( 2 )
c.
due to/ secondary to ( 2 )
“

d.
.
II Other significant conditions Including nutritional status, disability contributing to but not directly leading to the death.

Intervals
● seconds, minutes, hours, days, weeks, months, years.
● range such as seconds to minutes, minutes to hours, or "known for five years
● validates that the causes of death are written in the correct sequence.

All other significant factors or conditions

● Does not directly lead to the underlying cause of death

Reporting different numbers of causes of death

Case 2
A 56-year old man dies from acute myocardial infarction within 3 hours from its onset. He did not have any other
illnesses.
MEDICAL CERTIFICATE
ages 0 to 7 days accomplish items 14 19 a at the back )
( For -

19b CAUSES OF DEATH (if the deceased is aged 8 days and over ) Interval Between Onset and Death

I Immediate cause a Acute Myocardial Infarction 3 hours

Antecedent cause b

Underlying cause c.

II Other significant conditions contnbuting to death

Case 3
A 56-year old person dies from abscess of the lung (noted 5 days before death), which resulted from lobar
pneumonia of the left lung due to Streptococcal infection, diagnosed 2 weeks ago. History of pulmonary
tuberculosis was noted.
MEDICAL CERTIFICATE
(For ages 0 to 7 days, accomplish items 14 -19a at the back )
19b CAUSES OF DEATH (if the deceased is aged 8 days and over ) Interval Between Onset and Death

I Immediate cause a Lung Abscess, Left 5 days

Antecedent cause '
b Streptococcal pneumonia , lobar, left lung, community- acquired 2 weeks
Underlying cause : c.
II Other significant conditions contnbuting to death Pulmom- . uberculc

MEDICAL CERTIFICATE
(For ages 0 to 7 days, accomplish items 14-19a at the back )
19b CAUSES OF DEATH ( if the deceased is aged 8 days and over ) Interval Between Onset and Death

I Immediate cause : a. Lung Abscess, Left 5 days

Antecedent cause '
b Streptococcal pneumonia, lobar, left lung, community - acquired 2 weeks
Underlying cause c Pulmonary Tuberculosis, multiple drug resistant years

II Other significant conditions contnbuting to death

Case 4
A 32 year old man while crossing the road was hit by a truck, and sustained multiple fracture of both lower
extremities, close. He died from hypovolemic shock after 5 hours.
MEDICAL CERTIFICATE
(For ages 0 to 7 days, accomplish items 14-19a at the back )
19b CAUSES OF DEATH ( if the deceased is aged 8 days and over ) Interval Between Onset and Death

I Immediate cause a. Hypovolemic Shock 1 hour

Antecedent cause b Multiple Fractures 5 hours
Underlying cause c Pedestrian on foot in collision with truck 5 hours
II. Other significant conditions contnbuting to death

Case 5
A 32 year old man in a wheelchair while crossing the road was hit by a truck, and sustained blunt abdominal trauma
with liver laceration. He died from hypovolemic shock after 5 hours.
MEDICAL CERTIFICATE
(For ages 0 to 7 days, accomplish items 14-19a at the back )
19b CAUSES OF DEATH (if the deceased is aged 8 days and over ) Interval Between Onset and Death

I Immediate cause a Hypovolemic Shock 1 hour

Antecedent cause b ( i ... . o i . Dii . '

. -
o f d . O n. i K . . or ; .
. 5 hours; 5 hours
Underlying cause c. Pedestrian in a wheelchair in collision with truck 5 hours
II. Other significant conditions contnbuting to death:
Case 6
A 10-year old boy had a four-year history of Thalassemia Major. Four weeks prior to admission, the patient's mother
noted his easy fatigability and severe pallor. Upon medical consultation, they were informed that the boy had severe
microcytic anemia. Despite the medications and absence of strenuous activities, the patient complained of dyspnea
and easy fatigability one week prior to admission. The doctor explained that it was due to high output cardiac failure
and advised confinement. One day prior to admission, the patient complained of dyspnea and tiredness and slept
most of the time. At the ER, he was weak-looking, pale, hypotensive, with poor pulses and cold, clammy extremities.
C-B-C showed hemoglobin of 40 mg/dL. He was transfused one aliquot of packed RBC, but his condition
deteriorated, and he died the next day.
MEDICAL CERTIFICATE
(For ages 0 to 7 days, accomplish items 14 - 19a at the back )
19b CAUSES OF DEATH (if the deceased is aged 8 days and over ) Interval Between Onset and Death

I Immediate cause a Hypovolemic Shock 3 days

b H 9h output cardiac failure; Severe microcytic anemia 1 - 2 weeks; 4 weeks
Antecedent cause
'
Underlying cause c. Thalassemia Major 4 years
II Other significant conditions contnbuting to death

ILL-DEFINED CAUSES OF DEATH → do not give information needed to guide health policy and planning
● ICD-10:
○ vague categories, conditions, signs, symptoms, abnormal clinical & lab findings
○ Insufficiently detailed to be of value for public health purposes
● As a rule, refrain from reporting ill-defined cause of death, unless:
○ nothing else is known about the deceased
○ this is supported by an underlying specific cause of death or condition

Septicemia
MENINGITIS PNEUMONIA

INFECTED SKIN SEPTIC ABORTION

POSTOPERATIVE
INFECTED WOUND
INFECTION

→ considered ill-defined because can be due to several types of infection and origin
→ may be used as an immediate cause of death but not as underlying cause of death
Examples of Ill-defined Causes of Death

Disseminated Pulmonary
intravascular edema
disease

Cardiovascular
Ventricular disease:
tachycardia unspecified

Heart disease:
unspecified

Mode of dying
● If organ failure is reported on the Death Certificate, the underlying condition responsible for the failure
should also be reported
● Example:
○ Chronic Renal Failure secondary to Diabetes Mellitus Type II
○ Liver Failure secondary to Hepatitis B Infection

Mode of Dying: HEART FAILURE

MYOCARDIAL
INFARCTION

EXCESSIVE POST
DISSEMINATED
PARTUM PRIMARY CARCINOMA
HEMORRHAGE OF LEFT LUNG

CHRONIC RENAL
FAILURE
 Garbage Codes

Asphyxia Multi- organ Failure Shock

Asthenia Cardiac Failure Syncope
Exhaustion Hepatic Failure Uremia
Cachexia Hepatorenal Failure Vasovagal
Debility Kidney Failure Inhibition
Coma Renal Failure Vasovagal Attack
Brain Failure
Ventricular Failure

Mechanistic Terminal Events

● Terminal pathophysiological or biochemical derangements
● Common final pathways that explain how a cause of death exerts its lethal effect
○ Respiratory/ Cardiac /Cardiopulmonary Arrest
○ Asystole
○ Ventricular Fibrillation
○ Electromechanical Dissociation
● Should NEVER be reported in the COD
SESSION 6: Guidelines for Reporting Causes of Death in Specific Population Groups

Causes of Death in Specific Groups

FETUS INFANTS WOMEN OF ELDERLY

(0- 7 DAYS) CHILDBEARING AGE

Fetal Death
● Municipal Form 103A Certificate of Fetal Death
○ Certification of causes of fetal death is mandatory; i.e., death of a fetus, who is at least 20 weeks of
age of gestation or weigh more than 500 grams. The death can occur intrauterine or peripartum
(during delivery).

MEDICAL CERTIFICATE
19 CAUSES OF FETAL DEATH
a. Main disease/condition of fetus single most important, the main disease or condition that caused fetal death
b Other diseases/conditions of the fetus other disease or condition of the fetus that caused fetal death.
C Main maternal disease/condition affecting fetus single most important disease/ condition of MOTHER that caused fetal death

d Other maternal disease/condition affecting fetus other disease / condition of MOTHER that caused fetal death
e Other relevant circumstances cannot be identified as a condition or disease of mother nor fetus

20 FETUS DIED 1 Before Labor 2 Dunng labor/delivery 3 Unknown

21. LENGTH OF PREGNANCY uncompleted weeks 22a ATTENDANT {Pr.ysiciir Nine. Midkite Hilotor Trkdrtoni Biflti Attendant none otneo { specify )}

Fetal Death Case 1

A 38 year old G3P2 (2002) mother on her 34th week of gestation was admitted for preterm labor at a birthing facility.
After 6 hours, she delivered a stillborn baby boy with his umbilical cord wrapped around his neck. The fetus was
cyanotic with no gross fetal movement nor heartbeat.
MEDICAL CERTIFICATE
19. CAUSES OF FETAL DEATH
Single Cord Coil Around Neck
a Main disease/condition of fetus
b. Other diseases/conditions of the fetus
Asphyxia, Prematurity
c. Main maternal disease condition affecting fetus
/ Premature labor; 34 wks gestation
d. Other maternal disease/condition affecting fetus
e. Other relevant circumstances
20. FETUS DIED: X 1 Before Labor 2 During labor/delivery 3 Unknown
21 LENGTH OF PREGNANCY (in completed weeks) 22a. ATTENDANT {Phywaan. Nurse MxJwffe. M or Tradrtionai Birth Attendant none others (specify))
,

34 weeks ** , ,
Fetal Death Case 2
A 30 year old G3P2 (2002) mother, 35 weeks AOG, was admitted in the hospital due to noted absence of fetal
movements for 1 week. Ultrasound revealed fetal anencephaly. Labor was induced by the doctor and she delivered a
stillborn anencephalic fetus weighing 1200g.
MEDICAL CERTIFICATE
19 CAUSES OF FETAL DEATH
Anencephaly
a Main disease/condition of fetus
b. Other diseases/conditions of the fetus
Prematurity
c. Mam maternal disease/condition affecting fetus Premature lat weeks gestation
d. Other maternal disease/ condition affecting fetus
e. Other relevant circumstances
20. FETUS DIED X 1 Before Labor 2 Dunng labor/delivery 3 Unknown
21 LENGTH OF PREGNANCY (Й completed weeks) 22a. ATTENDANT (Pnywawi Мла Mdwfe HwjmrTraanixWBrtiMandart. ют . сттммоМ)
35 weeks Physician

Death in Infants Aged 0-7 Days

● Fill out Municipal Form 103
● Items 14 to 19a
FOR CHILDREN AGED 0 TO 7 DAYS
14 AGE OF MOTHER 15. METHOD OF DELIVERY (Normal spontaneous. 16 LENGTH OF PREGNANCY
vertex. if others, specify (in completed weeks )

17 TYPE OF BIRTH 18 IF MULTIPLE BIRTH CHILD WAS .

( Single. Twin. Triplet etc ) ( First . Second. Third etc . )
,

MEDICAL CERTIFICATE
19a CAUSES OF DEATH
a Main diease/condition of infant
b Other diseases/conditions of infant
c Main maternal disease/condition affecting infant
d Other maternal disease/condition affecting infant
e Other relevant circumstances
CONTINUE TO FILL UP ITEM 20
POSTMORTEM CERTIFICATE OF DEATH
I HEREBY CERTIFY that I have performed an autopsy upon the body of the deceased and that the cause of death was

● The mode of dying: asphyxia, heart failure, anoxia, and prematurity, should not be entered in section (a),
unless it was the only known condition.
● If any of these conditions is cited, the antecedent and underlying causes of death MUST be specified.

Neonatal Death Case 2

A 38 year old G3P2 (0020) mother, 24 weeks AOG, was admitted in a birthing facility for preterm labor. This spanned
6 hours and she subsequently delivered a 700 gram infant. The infant was transferred to a hospital and was admitted
at the neonatal intensive care unit but subsequently died after 48 hours. The chest x-ray showed severe hyaline
membrane disease.
FOR CHILDREN AGED 0 TO 7 DAYS
14 AGE OF MOTHER 15 METHOD OF DELIVERY (Normal vonttnnvt 16 LENGTH OF PREGNANCY
•.
« Hat if oei rs ipeciV
*
38 Normal Delivery 24 week
17 TYPE OF BIRTH 18 IF MULTIPLE BIRTH. CHILD WAS
(Fin Second T>wd ale.)
*
ПГЮАТЕ
19a CAUSES OF DEATH
a Mam diease/condition of infant
b Other diseases/condibons of infant
c Mam maternal disease/condition affecting infant
d Other maternal disease/conditoon affecting infant
e Other relevant circumstances
wni1NUE TO FILL UP ITEM 20
*Main disease may also be HMD

WOMEN OF CHILDBEARING AGE

● 15-49 y/o

Maternal Death
● Death from any cause related to or aggravated by the pregnancy or its management but not from injury or
incidental causes.
● While pregnant or within 42 days after termination irrespective of the duration and sign of pregnancy

ALL DEATHS (death during pregnancy, childbirth or puerperium)

MATERNAL DEATH OTHER DEATHS

DIRECT OBSTETRIC CAUSES INDIRECT CAUSES UNSPECIFIED

• hypertensive disorders • non- obstetric causes • unknown or • coincidental

causes
• obstetric hemorrhage (communicable diseases, undetermined
• external causes
• pregnancy - related infections non-communicable
• pregnancies with abortive outcome diseases, and nutritional
• other obstetric complications disorders
• unanticipated complications of that complicate the
management pregnancy leading to
death)

→ HPN: major killer of mothers in Phil (eclampsia, preeclampsia)

→ hemorrhage: atony, infections

MEDICAL CERTIFICATE
( For ages 0 to 7 days, accomplish items 14 - 19a at the back )
19b. CAUSES OF DEATH (if the deceased is aged 8 days and over ) Interval Between Onset and Death

I. Immediate cause : a.

Antecedent cause : b.

Underlying cause : c.

II. Other significant conditions contributing to death:

19c. MATERNAL CONDITION (If the deceased is female aged 15-49 years old)

a. pregnant, b. pregnant, in c. less than 42 days after d. 42 days to 1 year after e . None of the
not in labour labour delivery delivery choices

Death of Women in Childbearing Age Case 1

A 36-year old G5P5 (3114) woman who delivered a full-term baby boy at home, was brought to the emergency room
because of an hour of severe bleeding. She was hypotensive on her arrival at the emergency room. Whole blood
transfusion and manual extraction of the placenta were performed. However, she died four hours after placental
delivery.
 MEDICAL CERTIFICATE
ages 0 to 7 days , accomplish items 14 - 19a at the back )
( For
19b . CAUSES OF DEATH (if the deceased is aged 8 days and over ) Interval Between Onset and Death

I. Immediate cause : a. hypovolemic shock about 4 hours

Antecedent cause : b . . about 5 hours
Underlying cause : c. retained placenta about 5 hours
II. Other significant conditions contributing to death:

19c . MATERNAL CONDITION ( If the deceased is female aged 15-49 years old )

a pregnant.
. b. pregnant , in X c. less than 42 days after d. 42 days to 1 year after e. None of the
not in labour labour delivery delivery choices

ELDERLY
● 60 and above
● Most of the elderly apparently die "with the disease" and not from them
● CAUSE OF DEATH (of no value in health planning, research → Garbage Codes)
○ Old age, Senility
○ Senescence
○ Advanced age
○ Multi-organ failure

Elderly Death Case

A 95-year old man was found dead on his bed by his wife. He had chronic mild hypertension controlled by
medication. His previous chest x-ray shows mild cardiomegaly, consistent with chronic hypertension. There was no
suspicion nor evidence of foul play. No specific cause of death could be identified.

MEDICAL CERTIFICATE
(For ages 0 to 7 days, accomplish items 14 - 19a at the back )
19b . CAUSES OF DEATH (if the deceased is aged 8 days and over ) Interval Between Onset and Death

I . Immediate cause : a. undetermined natural cause

Antecedent cause : b.

Underlying cause : c.
II. Other significant conditions contributing to death: chronic mild hypertension

If the cause of death of the elderly cannot be determined, and upon careful analysis, it seems to be due solely to a
natural cause, the physician may report "Undetermined Natural Cause"

Elderly Death: Considerations

● Abuse/Neglect
● Inconspicuous Injuries
● Suicide

If in doubt, report immediately to the authorities

Beware of common complications of existing disease/s among elderly that may cause us to overlook and fail to report
the actual underlying cause of death.
Make the best judgment based on careful review of available clinical data

Are the ff correct underlying causes of death?

SEPSIS
PNEUMONIA
DECUBITUS ULCER

YES!!!!

Explore the true Underlying Cause of Death. Be meticulous in investigating.

SEPSIS Can be due to... URINARY TRACT INFECTION

CEREBRO- VASCULAR DISEASE, PULMONARY

PNEUMONIA DISEASE, CARDIAC DISEASE, DEMENTIA

DECUBITUS ULCER SPECIFIC DEBILITATING NEUROLOGICAL

DISEASE SUCH AS CEREBRAL PALSY
SESSION 7: Causes of Death in Specific Conditions

● EXTERNAL EVENTS OR INJURY

● PERIPROCEDURAL
● INFECTIONS
● NEOPLASM

Injuries: External Events (ICD-10)

● External event: physical or chemical agent/ force, that causes body trauma
● Body trauma: injury or damage to body tissues or its functions
● Fatal derangement: the deadly anatomic or functional effect of the trauma
● CAUSE OF DEATH
○ Immediate cause: the deadly anatomic or functional effect of the trauma
○ Antecedent cause: injury or damage to body/organs or its functions
○ Underlying cause: usually physical or chemical in nature, that causes trauma
19d DEATH BY EXTERNAL CAUSES 20 AUTOPSY
( Yes/No )
.
a Manner of death ( Homicide, Suicide Accident, Legal intervention etc )

b Place of Occurrence of External Cause (e g , home, farm, factory , street, etc )

NOTE: Death by violence → done by medicol-legal officer

Death Involving External Event Case 1

A 24-year-old male was brought to the ER unconscious. His BP was 80/40, and HR was 52 beats/minute, with
thready, weak pulses. There was a note of bleeding from his forehead 30 minutes prior to the consult. A witness
reported that the patient had an altercation with friends during a partywhere gunshots were heard. He expired about
an hour after the accident, despite resuscitative efforts.
MEDICAL CERTIFICATE
(For ages 0 to 7 days, accomplish items 14-19a at the back )
19b CAUSES OF DEATH (if the deceased is aged 8 days and over ) Interval Between Onset and Death

I. Immediate cause : a Brain stem herniation Less than 1 hour

Antecedent cause b. Cranio- cerebral Gunshot Injury 1 hour

Underlying cause Firearm discharge 1 hour

II Other significant conditions contnbuting to death;

19d DEATH BY EXTERNAL CAUSES 20 AUTOPSY

( Yes/No )
a Manner of death (Homicide. Suicide. Accident. Legal intervention, etc ) Unknown

b Place of Occurrence of External Cause (e g . home, farm, factory , street, etc. ) Unspecified place No

Death Involving External Event Case 2

A 36-year old male was brought in bleeding from the chest. The patient's blood pressure was palpatory, with a heart
rate of 36/min, and stab wounds on the right chest. Thirty minutes prior to admission, he was reported to be in a fight
during a party and was found bleeding and thus rushed to the hospital. Intraoperative Findings were intrathoracic
hemorrhage on the right, with transection of the right subclavian artery. About thirty minutes from admission, the
patient died in the operating room.
 MEDICAL CERTIFICATE
( For ages 0 to 7 days, accomplish items 14 -19a at the back )
19b CAUSES OF DEATH (If the deceased is aged 8 days and over ) Interval Between Onset and Death

I. Immediate cause a m9ht intrathoracic hemorrhage 30 minutes

Transection of right subclavian artery;
Antecedent cause b Multiple stab wounds, riaht upper chest 1 hour; 1 hour

Underlying cause c Contact with sharp object 1 hour

II. Other significant conditions contnbuting to death

19d DEATH BY EXTERNAL CAUSES 120 AUTOPSY

a Manner of death ( Homicide. Suicide. Accident. Legal intervention, etc ) Unknown ( Yes /No )

b. Place of Occurrence of External Cause (e g . home, farm, factory, street etc.I Unspecified place
,
No

Death Involving External Event or Injuries & ICD-10 Codes

● ICD-10: 10th revision of the International Statistical Classification of Diseases and Related Health Problems
(ICD) of the WHO
● Attempt to have standard medical terms globally.
● Used by PhilHealth for insurance claims for services rendered to the sick or injured patients
● Used by the PSA to code the Underlying Causes of Death
○ Centralized coding done by PSA - risk in non-centralized coding will cause misclassification or
information bias

Death Involving External Injury Case 3

A 23-year old male farmer from Quezon, while harvesting coconuts for copra, fell from the tree and landed on his
right side. He was immediately transported to the hospital two hours away but he was declared dead on arrival. On
autopsy, there was massive intra-abdominal hemorrhage and a laceration of the liver.
MEDICAL CERTIFICATE
(For ages 0 to 7 days, accomplish items 14-19a at the back )
19b CAUSES OF DEATH (if the deceased is aged 8 days and over ) Interval Between Onset and Death

I Immediate cause a Intra - abdominal hemorrhage 2 hours

Antecedent cause : b Laceration of Liver; Blunt Force Trauma of Abdomen 2 hours; 2 hours

Underlying cause ; c. Fall from a tree 2 hours

II. Other significant conditions contributing to death

19d DEATH BY EXTERNAL CAUSES 20 AUTOPSY

a Manner of death ( Homicide. Suicide. Accident. Legal intervention , etc ) Unknown ( Yes/ No )

b Place of Occurrence of External Cause (e g . home, farm, factory , street, etc. ) Unspecified place No
 MEDICAL CERTIFICATE
( For ages 0 to 7 days , accomplish items 14 -19a at the back )
19b. CAUSES OF DEATH (if the deceased is aged 8 days and over ) Interval Between Onset and Death

I. Immediate cause a Laceration of Liver 2 hours

Antecedent cause b Blunt Force Trauma of Abdomen 2 hours

Underlying cause : c. Fall from a tree 2 hours

II. Other significant conditions contnbuting to death

19d DEATH BY EXTERNAL CAUSES 20 AUTOPSY

a Manner of death (Homicide. Suicide. Accident, Legal intervention, etc ) Unknown ( Yes/No )

b Place of Occurrence of External Cause (e g . home farm, factory street, etc

, ) Unspecified place No

Reporting Requirements: Death Involving Vehicular Crashes

● Indicate whether the deceased was a driver, passenger, or pedestrian
● Type of vehicle (e.g. car, truck, train, motorcycle) → explains mechanism of injury

Death Involving External Injury Case 4

A 26-year old female crossed Commonwealth Avenue with her purchases from the market when she got hit by an
incoming motorbike moving at 100 km per hour. In the ambulance, the patient complained of a headache, then
became unconscious. At the hospital, an emergency MRI showed a subarachnoid Hemorrhage. The patient died in
transit to the operating room.
MEDICAL CERTIFICATE
(For ages 0 to 7 days, accomplish items 14-19a at the back )
19b. CAUSES OF DEATH (if the deceased is aged 8 days and over ) Interval Between Onset and Death

I. Immediate cause a Subarachnoid hemorrhage minutes

Antecedent cause : b. Blunt trauma of head minutes

Underlying cause : c. Pedestrian hit by a moving motorbike minutes

II. Other significant conditions contributing to death

19d DEATH BY EXTERNAL CAUSES 20 AUTOPSY

Accident ( Yes/ No )
a Manner of death (Homicide. Suicide. Accident. Legal intervention , etc.)

b. Place of Occurrence of External Cause ( e g home, farm, factory street etc )

, ,
Street and Highway No

Death Involving External Events or Injuries & ICD-10 Codes

ICD 10 TERMS
Gunshot wound → Firearm discharge
Stab wound → Contact with a sharp object
Vehicular crash injury → Person (pedestrian/driver/passenger) injured in unspecified motor-vehicle accident, traffic
Falls → Fall from tree (Slipping, tripping, stumbling, and falls)
 Details in Reporting External Injuries

Number Site Laterality Part of Contamination Open or Degree & %

bone/body close of B.S.

Example 2, multiple arm left Upper thorax With foreign close 2nd degree,
body 18% B.S.

Blunt trauma

Wound

Stab

Gunshot

Fracture

Bums

Periprocedural Deaths
● Death known or suspected as having resulted completely or partly from a medical procedure:
○ Diagnostic
○ Operative
○ Therapeutic
○ Anesthetic
● Do NOT use these terms (may connote negligence):
○ "Misadventure"
○ "latrogenic"
○ "Error or accident in medical care"
● Many periprocedural deaths do not actually involve negligence, mistake, or culpability.
● There are major concerns about wording and the format of cause-of-death
● These may:
○ foster litigation
○ unnecessarily implicate or alienate a physician, other medical personnel, or health facility
○ unnecessarily alarm family members of survivors
● Problems may also result if the COD is oversimplified or omits known complications.
● May be perceived as an attempt to conceal facts or cover up a problem.
● Based on documented or reasonably probable facts, state the truth to the best of one's knowledge.
● To ensure proper coding, there are two important rules:
○ First, the certifier should specify the appropriate category.
○ Second, proper format should be observed.
● The structure and format used in writing the cause-of-death statements depend on the manner of death.
● Natural vs Accidental
○ Natural: patient is dying even before the procedure or the patient would have died without the
procedure.

Appropriate Periprocedural Death Categories

Timing Type of Procedure

Peri Diagnostic
Anesthetic
Intra
Therapeutic
Post Operative
Periprocedural Deaths: Case 1
A 54-year old male known hypertensive with atherosclerotic coronary heart disease and adenocarcinoma of the
colon was admitted to the hospital. About 30 minutes after the surgical/abdominal opening, the patient
decompensated. He died despite an hour of resuscitation measures. On autopsy, there was a myocardial infarction
documented.
MEDICAL CERTIFICATE
(For ages 0 to 7 days, accomplish items 14 -19a at the back )
19b CAUSES OF DEATH (if the deceased Is aged 8 days and over ) Interval Between Onset and Death

I immediate cause a. Intraoperative myocardial infarction 1 hour

Antecedent cause : b. Colectomy 1.5 hours

Underlying cause c. Primary adenocarcinoma, colon months
ll Other significant conditions contnbuting to death Atherosclerotic Coronary Heart Disease

Periprocedural Deaths: Natural

● Natural Periprocedural Death: patient's death was imminent, would occur without the procedure usually
emergency/life-saving procedure
● Use COMBINED FORMAT, where everything is reported in Part l.
MEDICAL CERTIFICATE
(For ages 0 to 7 days , accomplish items 14-19a at the back )
19b CAUSES OF DEATH (if the deceased is aged 8 days and over ) Interval Between Onset and Death

I Immediate cause a Fatal complication of the procedure that caused death

Antecedent cause ь The procedure that caused the complication
Underlying cause c. The medical condition: the reason for doing the procedure
II Other significant conditions contnbuting to death

Periprocedural Death Case: Natural Case 1

An elderly male patient with refractory congestive heart failure was given a high dose of digoxin for effective cardiac
output maintenance. He had no medical complaints for the next three months. However, he complained of nausea
and vomiting two days prior to the consult.The patient believed that it was just indigestion and would heal soon. He
was found unconscious in his bed minutes before admission. Resuscitative efforts failed, and the ER Officer
explained that he died of Digoxin toxicity.
MEDICAL CERTIFICATE
(For ages 0 to 7 days , accomplish items 14 -19a at the back )
19b. CAUSES OF DEATH (if the deceased is aged 8 days and over) Interval Between Onset and Death

I. Immediate cause a Digoxin toxicity More than 2 days

Antecedent cause b Peritherapeutic complication of digoxin therapy weeks

Underlying cause c Atherosclerotic coronary heart disease years

II Other significant conditions contnbuting to death

Accidental Periprocedural Death

● Death would not have occurred in the procedure's absence or if the procedure was not done
● Procedure usually elective
● Use split format in writing the cause of death
 MEDICAL CERTIFICATE
(For ages 0 to 7 days, accomplish items 14-19a at the back)
19b CAUSES OF DEATH (If the deceased Is aged 8 days and over ) Interval Between Onset and Death

l immediate cause a Complication that caused death

Antecedent cause b Procedure that caused the complication

Underlying cause : c.
II Other significant conditions contnbuting to death Medical condition which was the reason for doing procedure

19d DEATH BY EXTERNAL CAUSES 120. AUTOPSY

a Manner of death (Homicide. Suicide. Accident. Legal intervention, etc.) Accident ( Yes /No )

b Place of Occurrence of External Cause (e g . home. farm, factory, street, etc ) Hospital

Periprocedural Deaths: Accidental (Case 1)

A 54-year-old male with a history of chronic chest pain was admitted for elective angioplasty with stent placement for
coronary artery disease. About twenty minutes after the start of the catheterization, the right coronary artery was
inadvertently ruptured. Five minutes later, cardiac tamponade was detected, and the patient died 10 minutes
thereafter.
MEDICAL CERTIFICATE
( For ages 0 to 7 days, accomplish items 14-19a at the back )
19b CAUSES OF DEATH (if the deceased is aged 8 days and over ) LInterval Between Onset and Death

I Immediate cause a Cardiac tamponade 10 minutes

Antecedent cause : b. Intraoperative rupture of the coronary artery 15 minutes

Underlying cause c Cardiac catheterization for angioplasty 35 minutes

and stent replacement
II Other significant conditions contnbuting to death

19d DEATH BY EXTERNAL CAUSES 20 AUTOPSY

a Manner of death ( Homicide. Suicide. Accident . Legal intervention, etc.) Accident ( Yes/No )

Hospital No
b Place of Occurrence of External Cause (e g . home, farm, factory , street, etc )

Periprocedural Deaths: Writing Format

MANNER NATURAL ACCIDENTAL

Format Combined Split

Parti Immediate Fatal complication Fatal complication

cause

Antecedent Complication of the Complication of the

cause procedure procedure

Underlying Medical condition Procedure

cause requiring procedure

Part II Other significant Medical condition

requiring procedure
Periprocedural Death Case: Natural Case 2
A 45-year-old patient with a history of IV drug abuse and AIDS was admitted for Pneumocystis jiroveci pneumonia.
On the 3rd day of confinement, her progressive dyspnea and hypoxia required positive pressure ventilatory support.
Later, the patient became restless and complained of chest pain and dyspnea. Physical examination revealed
Bilateral Pneumothorax, most probably ventilator pressures. The patient died 5 minutes after complaining of chest
pain.
MEDICAL CERTIFICATE
(For ages 0 to 7 days, accomplish items 14-19a at the back )
19b CAUSES OF DEATH (if the deceased is aged 8 days and oven Interval Between Onset and Death

I. Immediate cause a Bilateral pneumothorax More than 5 minutes

Peritherapeutic complication of ventilatory More than 5 minutes;
Antecedent cause Ь cnpprirt - Pnoiimr^yctic jirr io/A pnonmnnin
\\ mnro than t rtayc

Underlying cause C AIDS years

Intravenous drug abuse
II. Other significant conditions contnbuting to death

Reporting Requirements: Death from Infection

MUST INCLUDE:
● Manifestation or body site
● Causative agent
○ if known based on laboratory results
○ Causative agent is identified to be "presumed" or "probable" based on current known epidemiology
e.g, intra-abdominal infection is PRESUMED or PROBABLY due to E. coli; cellulitis is PRESUMED
or PROBABLY due to Staphylococcus sp.
○ If causative agent is unknown, you may write "cause unknown"
● Source and route of infection
● Underlying disease that may have suppressed the deceased's immunity
● Community-acquired or health facility-associated

Report underlying disease that may have suppressed the patient's immunity and made him susceptible to the fatal
infection. → Underlying COD
● Examples: Cancer, use of immunosuppressive drugs for rheumatologic diseases, and HIV AIDS.

Death from Infection: Case 1

A 29-year-old male diagnosed with HIV-AIDS was admitted to the hospital for difficulty of breathing. Chest x-ray
showed pneumonia, and ETA culture showed growth of Pneumocystis jiroveci. The patient expired after four days.
MEDICAL CERTIFICATE
( For ages 0 to 7 days, accomplish items 14 -19a at the back )
19b CAUSES OF DEATH (if the deceased is aged 8 days and over) Interval Between Onset and Death

I. Immediate cause Pneumocystis jiroveci Pneumonia More than 4 days

Antecedent cause b AIDS Months

Underlying cause : c. HIV Infection Years

II Other significant conditions contnbuting to death

HIV/AIDS → the only accepted abbreviations

MCCOD for COVID-19

● A death due to COVID-19:
○ Is defined for surveillance purposes as a death resulting from a clinically compatible illness, in a
probable or confirmed COVID-19 case
 ○ May not be attributed to another disease and should be counted independently of preexisting
conditions that are suspected of triggering a severe course of COVID-1
● RECORDING COVID-19 ON THE MEDICAL CERTIFICATE OF CAUSE OF DEATH
○ COVID-19 should be recorded on the medical certificate of cause of death for ALL decedents
where the disease caused, or is assumed to have caused, or contributed to death.
● TERMINOLOGY
○ "COVID-19" should be used for all certification of this cause of death.
○ It is recommended not to use "coronavirus" in place of COVID-19 - several types of coronaviruses.
● Emergency ICD-10 Codes
○ U07.1: laboratory confirmed COVID-19 cases
○ U07.2: suspected and probable COVID-19 cases
● DOH Circular 2020-0202
○ Guidance for Certifying Corona Disease 2019 or COVID-19 Deaths
○ Laboratory-confirmed deaths: requires Official Confirmatory Test for COVID-19

MEDICAL CERTIFICATE
(For ages 0 to 7 days, accomplish items 1419a at the back)
19b. CAUSES OF OEATH (if the deceased is aged 8 days and over ) Interval Between Onset and Death

.
I Immediate cause : a. Acute Respiratory Distress Syndrome 2 davs

Antecedent cause : b. Pneumonia 10 davs

Underlying cause : c. COVID- }9 ( laboratory -confirmed) 14 davs

. -
II Other significant conditions contributing to death: Identified co morbidities should be written in this portion such
. .
as Hypertensive Cardiovascular Disease Diabetes Mellitus Туре II Asthma. Emphysema, etc.

● Maternal deaths due to circumstances aggravated by COVID-19

MEDICAL CERTIFICATE
-
( For ages 0 to 7 days, accomplish items 14 19a at the back)
19b. CAUSES OF DEATH (if the deceased is aged 8 days and over) Interval Between Onset and Death
. .
I Immediate cause : a Respiratory Failure 2 davs

Antecedent cause : b. Pneumonia 10 davs

Underlying cause : c. Pregnancy complicated bv COVID-19 12 davs
II. Other significant conditions contributing to death: Identified co- morbidities should be written in this portion such
.
as Hypertensive Cardiovascular Disease Diabetes Mellitus Type II. Asthma. Emphysema, etc.
19c. MATERNAL CONDITION (if the deceased is female aged 15-49 years old)
X a. pregnant. b. pregnant, in c. less than 42 days after .
d 42 days to 1year e. None of the
not in labour labour delivery after delivery choices

● Death of persons with COVID-19 but died due to other conditions

 MEDICAL CERTIFICATE
(For ages 0 to 7 days, accomplish items 14-19a at the back )
19b. CAUSES OF DEATH ( if the deceased is aged 8 days and over ) Interval Between Onset and Death
I. Immediate cause : a . Subarachnoid hemorrhage 1 hour

Antecedent cause : b. Blunt trauma of head 1 hour

Underlying cause : c. Car passenger in collision with truck 1 hour

II. Other significant conditions contributing to death: COVID - 19

L 9d. DEATH BY EXTERNAL CAUSES 20. AUTOPSY

(Yes/No)
.
a. Manner of death (Homicide Suicide, Accident, Legal intervention, etc.) Accident

b. Place of Occurrence of External Cause ( e.g., home, farm, factory, street, etc.) Hist v NO

Death from Infection: Case 2

A 65-year-old post-MI, hypertensive, obese man visited his son in South Korea from February 8-16, 2020. Upon
arrival in Manila, his temperature was 38.9 degrees celsius with intermittent cough and headache. After three days,
his fever persisted, and he complained of shortness of breath. He was brought to a nearby hospital and was
eventually intubated after two days. Chest X-ray showed bilateral ground-glass opacities with consolidation on the
right mid to lower lung fields. SARS-CoV-2 PCR test was positive. He eventually expired after two days of intubation.

MEDICAL CERTIFICATE
(For ages 0 to 7 days, accomplish items 14 - 19a at the back )
19b CAUSES OF DEATH (if the deceased is aged 8 days and over ) Interval Between Onset and Death

I . Immediate cause : a. Pneumonia 4 days

Antecedent cause b COVID- 19 (Laboratory- confirmed) 8 days
Underlying cause : c.
II Other significant conditions contnbutmg to death Post Myocardial Infarction, Hypertension, Obesity

Death Death from Infection: Case3

A 66-year old male was admitted for cough and dyspnea, which worsened over two days prompting consult and
admission. At the ER the patient was tachypneic and febrile. Despite aggressive care, the patient deteriorated:
severe hypoxemia prompted intubation and transfer to the ICU on the 5th hospital day. He expired two days later.
Chest radiograph showed diffuse bilateral coalescent opacities. COVID-19 RT PCR test results were pending at the
time of demise. The patient owned a shop populaty visited by local and foreign tourists. He had diabetes and
hypertensive heart disease. He was "strong and active, and has not been hospitalized in at least 40 years".

MEDICAL CERTIFICATE
(For ages 0 to 7 days, accomplish items 14- 19a at the back )
19b CAUSES OF DEATH (if the deceased is aged 8 days and over ) Interval Between Onset and Death

I Immediate cause a Acute Respiratory Disease Syndrome 2 days

Antecedent cause : b Pneumonia 9 days

Underlying cause : c. Suspected COVID - 19 ( not laboratory - confirmed ) More than 9 days

II Other significant conditions contnbutmg to death Diabetes Mellitus Type 2 , Hypertensive Cardiovascular Disease
Reporting Requirements: Death from Hospital-acquired or Care-related Infections
● MOST COMMON
○ bloodstream infection
○ pneumonia
○ (e.g., ventilator-associated pneumonia)
○ urinary tract infection
○ surgical site infection

Death from Hospital-acquired or Care-related Infections

● If the health care-associated infection contributed to death, it should be reported similarly, but describe in:
○ line (a) the health-care related IMMEDIATE cause of death.
● Then all disease conditions in sequence of events:
○ line (b) ANTECEDENT cause, then
○ line (c) the UNDERLYING cause or the original disease being treated.

Death from Hospital-acquired or Care-related Infections: Case 4

A 54-year old male with psoriasis was admitted to the hospital seven days ago for right leg swelling. He was treated
for necrotizing fasciitis due to Staphylococcus aureus. On the second hospital day, the patient developed a cough,
was intubated, and was given IV antibiotics. Chest X-ray showed pneumonia on the right lung field, and endotracheal
aspirate showed Pseudomonas sp. He expired on his 7th day of confinement.

MEDICAL CERTIFICATE
(For ages 0 to 7 days, accomplish items 14-19a at the back )
19b. CAUSES OF DEATH (if the deceased is aged 8 days and over ) Interval Between Onset and Death

I. Immediate cause a Hospital- acquired Pseudomonas Pneumonia 5 days

Necrotizing Fasciitis of the right leg
Antecedent cause : b. due to Staphylococcus aureus More than 7 days

Underlying cause : c. Psoriasis years

II. Other significant conditions contnbuting to death

Reporting Requirements: Death from Neoplasms/ Cancer

● Specific site of neoplasm
● Primary site must be stated even if it has long been removed before death
● If unknown, write "Primary Unknown"
● Behavior of tumor:
○ benign or malignant
● Nature or histologic type (if known)
● When a secondary growth contributed to death, state the site of secondary growth.

Death from Neoplasm: Case 1

A 72-year-old male complained of non-specific but persistent right flank pain. On examination, he had icteric sclerae,
which was noted two months ago. MRI of the abdomen revealed a liver mass, and its biopsy showed
adenocarcinoma. The patient refused to undergo further treatment and went home. He was reported to have died two
months later.
 MEDICAL CERTIFICATE
(For ages 0 to 7 days, accomplish Items 14-19a at the back )
19b CAUSES OF DEATH (if the deceased is aged 8 days and over) Interval Between Onset and Death

I Immediate cause : a. Secondary adenocarcinoma of liver More than 4 months

Antecedent cause b Primary unknown years

Underlying cause : c.

II Other significant conditions contributing to death

Death from Neoplasm: Case 2

A 43-year-old female consulted you for non-specific right flank pain for the last six months. She underwent a modified
radical mastectomy of the LEFT breast for adenocarcinoma three years ago. MRI of the abdomen revealed a liver
mass, and biopsy showed adenocarcinoma. She refused further treatment and decided to go home. She was
reported to have died six months later.

MEDICAL CERTIFICATE
-
(For ages 0 to 7 days, accomplish items 14 19a at the back )
19b CAUSES OF DEATH (if the deceased is aged 8 days and over ) Interval Between Onset and Death

I immediate cause a. Secondary adenocarcinoma of liver 1 year

Antecedent cause b Primary adenocarcinoma of left breast More than 3 years

Underlying cause : c.

II . Other significant conditions contributing to death

Session 8: Verbal Autopsy

● WHO has recommended verbal autopsy as a partial solution to the lack of cause of death information when
there is no medical attendance or when a person dies in the absence of a physician.

Verbal autopsy
● A process for diagnosing causes of death of one who died in the absence of a health professional
● Is based on the responses of reliable family members and/or caregiver series of structured questions
regarding signs and symptoms experienced by the deceased prior to death.
● Signs
● Symptoms
● Medical history
● Circumstances preceding death

Verbal autopsy: Purpose

● To describe causes of death at the community level
○ where civil registration and death certification systems are limited
○ where deaths often occur at home

Practical uses of verbal autopsy

● Death that occur outside health facilities
● Deaths in health facilities with limited diagnostic capability
● Delayed registration of deaths
● Dead-on-arrival cases

Other uses of verbal autopsy

● As a source of cause-of-death statistics
● As a research tool
● In communities where the civil registration and death certification system is weak.
● policy planning, priority-setting, benchmarking and monitoring

Verbal autopsy: Assumptions

1. Patterns: Each disease that is a cause of death has a DISTINCT PATTERN of signs, symptoms, severity,
and other characteristics.
2. Recognitions: The signs and symptoms experienced by the deceased can be RECOGNIZED,
REMEMBERED, AND REPORTED by family members and/or caregivers.
3. Diagnosis: It is possible to correctly DIAGNOSE COD based on reported information, and to categorize
them into groups of COD that are useful for public health purposes.

Standard verbal autopsy instruments

● Physician-coded verbal autopsy questionnaire
● Automated verbal autopsy

2 stages in physician-coded verbal autopsy

● STAGE 1: The primary caregiver who was with the deceased in the period leading to death is interviewed
using a standard questionnaire.
● STAGE 2: Pattern of responses is reviewed by a physician ONLY to determine probable cause of death.

PRINCIPLE BEHIND A PHYSICIAN-REVIEWED VERBAL AUTOPSY

● ASSUMPTION:
○ Only physicians can correctly interpret the signs, symptoms, medical history and circumstances
surrounding the death of the deceased, thus accurately assigning an accurate cause of death
Improbable or Inconsistent Medical History
● PNP
● NBI