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Medical Examiners' and Coroners' Handbook on Death Registration

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Medical Examiners' and Coroners' Handbook on Death Registration National Center for Health Statistics Edward J. Sondik, Ph.D., Director Jack R. Anderson, Deputy Director Jack R. Anderson, Acting Associate Director for International Statistics Jennifer H. Madans, Ph.D., Associate Director for Science Lawrence H. Cox, Ph.D., Associate Director for Research and Methodology Diane M. Makuc, Dr.P.H., Acting Associate Director for Analysis, Epidemiology, and Health Promotion P. Douglas Williams, Acting Associate Director for Data Standards, Program Development, and Extramural Programs Edward L. Hunter, Associate Director for Planning, Budget, and Legislation Jennifer H. Madans, Ph.D., Acting Associate Director for Vital and Health Statistics Systems Douglas L. Zinn, Acting Associate Director for Management and Operations Charles J. Rothwell, Associate Director for Information Technology and Services Division of Vital Statistics James A. Weed, Ph.D., Acting Director James A. Weed, Ph.D., Acting Chief, Mortality Statistics Branch Preface This handbook contains instructions for medical examiners and coroners on the registration of deaths and the reporting of fetal deaths. It was prepared by the Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics (NCHS). These instructions pertain to the 2003 revisions of the U.S. Stan­ dard Certificate of Death and the U.S. Standard Report of Fetal Death and the 1992 revision of the Model State Vital Statistics Act and Regulations. This handbook is intended to serve as a model that can be adapted by any vital statistics registration area. Other handbooks and references on preparing and registering vital records are mentioned at the end of the section on ‘‘Medical Certification of Death’’ and are listed in the references. For most of these resources, the State vital statistics office or NCHS will be able to provide as many copies as requested. iii Acknowledgments This publication was prepared by staff from the Division of Vital Statistics led by Donna L. Hoyert, Ph.D., and Arialdi M. Minino, M.P.H. Martha L. Munson, M.S., provided content for fetal death items. Robert N. Anderson, Ph.D., also contributed to this handbook. Mary Anne Freedman, M.A., the Director of the Division of Vital Statistics while this publication was being prepared, reviewed and commented on the contents. Expert medical re- view and comments were provided by Randy Hanzlick, M.D.; Gregory G. Davis, M.D.; and Lillian R. Blackmon, M.D. This handbook was edited by Kathy Sedgwick, typeset by Jacqueline M. Davis, and the graphics produced by Jarmila G. Ogburn of the Publica­ tions Branch, Division of Data Services. Questions about mortality and cause-of-death issues may be directed to staff in the Mortality Statistics Branch, whereas questions about fetal death issues may be directed to Joyce A. Martin, M.P.H., or other staff in the Reproductive Statistics Branch of the Division of Vital Statistics, the Centers for Disease Control and Prevention’s National Center for Health Statistics, Hyattsville, MD 20782. v Contents Preface ............................................................. iii Acknowledgments ................................................... v Introduction ........................................................ 1 Purpose .......................................................... 1 Importance of Death Registration and Fetal Death Reporting ....... 2 U.S. Standard Certificates and Reports ............................ 4 Confidentiality of Vital Records .................................... 5 Responsibility of Medical Examiner or Coroner .................... 5 Death Registration ............................................. 5 Fetal Death Reporting .......................................... 7 General Instructions for Completing Certificates and Reports ........ 9 Medical Certification of Death ...................................... 11 Certifying the Cause of Death .................................... 11 Cause of Death .................................................. 11 Changes to Cause of Death ...................................... 14 Instructions ..................................................... 14 Part I of the Cause-of-death section ............................ 15 Line (a) Immediate Cause ................................... 15 Lines (b), (c), and (d) Due to (or as a Consequence of) ........ 16 Approximate Interval Between Onset and Death ............. 16 Part II of the Cause-of-Death section (Other Significant Conditions) .................................................. 17 Other Items for Medical Certification ............................. 18 Autopsy ....................................................... 18 Circumstances of Injury or Violence ........................... 19 Special Problems for the Medical-Legal Officer .................... 20 Precision of Knowledge Required to Complete Death Certificate Items ........................................................ 20 Trauma as a Cause of Death .................................. 20 Natural ..................................................... 21 Accident .................................................... 21 Suicide ..................................................... 21 Homicide ................................................... 21 vii Could not be Determined ................................... 21 Pending Investigation ....................................... 21 Determining a Suicide ......................................... 21 When Cause Cannot be Determined ........................... 22 Deferred ‘‘Pending Investigation’’ ............................... 22 Certifier Section ................................................. 24 Examples of Medical Certification ................................ 25 Common Problems in Death Certification ........................ 40 Additional Resources ............................................ 42 Completing Other Items on the Death Certificate ................... 43 About the Decedent (Items 1–19, 51–55) ......................... 43 Parents (Items 11 and 12) ....................................... 52 Informant (Items 13a–c) ......................................... 52 Place of Death (Items 14) ........................................ 53 Facility (Items 15–17) ............................................ 54 About the Disposition (Items 18–23) .............................. 55 Pronouncement (Items 24 and 25) ............................... 57 Pronouncing Physician (Items 26–28) ............................ 58 Date of Death (Item 29) .......................................... 59 Time of Death (Item 30) .......................................... 60 Medical Examiner or Coroner Contacted (Item 31) ................ 61 Cause of Death (Item 32) ........................................ 61 Autopsy (Items 33 and 34) ....................................... 62 Tobacco Use Contribute to Death (Item 35) ....................... 63 If Female, Pregnancy Status (Item 36) ............................ 63 Manner of Death (Item 37) ....................................... 63 Accident or Injury (Items 38–44) ................................. 64 Certifier (Items 45–49) ........................................... 67 Decedent’s Education (Item 51) .................................. 69 Decedent of Hispanic Origin (Item 52) ............................ 69 Race (Item 53) ................................................... 70 Occupation and Industry of Decedent (Items 54 and 55) .......... 71 Completing the Cause of Fetal Death ............................... 74 Cause of Fetal Death ............................................ 74 Supplemental Report of Cause of Fetal Death .................... 77 Other Items for Medical Certification ............................. 77 Examples of Reporting Cause of Fetal Death ..................... 78 Common Problems in Fetal Death Certification ................... 81 Completing the Report of Fetal Death .............................. 83 FACILITY WORKSHEET ......................................... 83 CAUSE OF FETAL DEATH ..................................... 95 PATIENT WORKSHEET .......................................... 98 viii References ....................................................... 105 Appendixes A. The U.S. Standard Certificate of Death ....................... 108 B. Decedent’s Educational Level Selection Card ................. 110 C. Race and Hispanic Origin Category Selection Cards .......... 111 D. The U.S. Standard Report of Fetal Death ..................... 112 E. Definitions of Live Birth and Fetal Death ..................... 114 F. Facility Worksheet for the Report of Fetal Death .............. 115 G. Patient’s Worksheet for the Report of Fetal Death ............. 123 H. The Vital Statistics Registration System in the United States . 128 ix Introduction Purpose This handbook is designed to acquaint medical examiners and coroners with the vital registration system in the United States and to provide instructions for completing and filing death certificates and fetal death reports. Emphasis is directed toward the certification of medical informa­ tion relating to these events when they come within the jurisdiction of the medical-legal officer (i.e., medical examiner or coroner). A significant number of the deaths occurring in the United States must be investigated and certified by a medical-legal officer. Although State laws vary in specific requirements, deaths that typically require investigation are those due to unusual or suspicious circumstances, violence (accident, suicide, or homicide),
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