As a part of the ongoing effort to improve cause of death documentation and reporting, we have developed several resources and training materials for medical facilities.
Physicians and medical staff completing death certificates may need a quick review of the concepts of cause of death documentation. The Cause of Death Instructions describes basic steps to completing the Cause of Death section on the death certificate.
We will soon begin to query physicians and medical certifiers for additional information when the cause of death lacks appropriate detail. The Department of Health will send a notification that a query has been initiated. Following the instructions of the query prompt, the physician will submit a Cause of Death Query Amendment (PDF) in the Electronic Death Registration System (EDRS) to update the Cause of Death with additional detail. Response to these queries is essential in improving the quality of cause of death data, evaluating the leading causes of death and the magnitude of certain health outcomes within our communities, and creating effective public health policy. Facilities will be notified in advance of death query activities.
We require all users of the Electronic Death Registration System to complete an eLearning course. This requirement was implemented in response to evidence of poor quality documentation and recognition of a lack of training on this topic in New York City. The course teaches physicians and medical facility staff who complete death certificates how to accurately complete the Cause of Death section, when to refer a case to the Office of Chief Medical Examiner, and the importance of accurate cause of death data that informs public health statistics, programs, and policies.
The physician must have access to the decedent's medical chart when determining the cause of death for death registration. The Death Worksheet (PDF), allows the physical transfer of cause of death information from the location of the death/medical chart to an EDRS workstation. The attached Death Worksheet is optional. The worksheet must be completed by a physician and may not be used for death registration. Use of the Death Worksheet is encouraged when the cause of death is documented sometime after the death, when the medical chart is not usually available at the EDRS workstation, and/or when the certifying physician was not the decedent's attending physician.
The Quality Improvement Unit of the Office of Vital Statistics is dedicated to improving the quality of vital event data by providing education and training to data providers. The newsletter titled 'Cremation Clearance: Requirements for Medical Examiner Approval' (PDF) is the first in a series of quality improvement newsletters that will be distributed to hospitals and facilities that report deaths.