Chinese Medical Record English Edition

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Quality Analysis of Death Medical Certificate

Reporting

Fang Liu, Na Sun & Jing Ni

To cite this article: Fang Liu, Na Sun & Jing Ni (2013) Quality Analysis of Death
Medical Certificate Reporting, Chinese Medical Record English Edition, 1:1, 14-16, DOI:
10.3109/23256176.2013.780743

To link to this article: http://dx.doi.org/10.3109/23256176.2013.780743

Published online: 02 Apr 2013.

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 Chinese Medical Record English Edition, 2013; 1(1): 14–16
© 2013 Chinese Medical Record Association
ISSN 2325-6176 online
DOI: 10.3109/23256176.2013.780743
Quality Analysis of Death Medical Certificate Reporting
Liu Fang, Sun Na and Ni Jing
Quality Management Department of General
Hospital of Chengdu Military Region, Chengdu,
Sichuan Province, P. R. China
Citation: Liu F, Sun N, Ni J. Quality Analysis of Death
Medical Certificate Reporting. Chin Med Rec
Engl Ed, 2013; 1(1): 14–6.
Downloaded by [McMaster University] at 13:20 16 April 2016
Address correspondence to: Liu Fang, Quality
Management Department of General Hospital of
Chengdu Military Region, Chengdu 610083, Sichuan
Province, P. R. China.
Abstract
Objective. Analyzing reporting quality of the death medical certificate is
to improve the accuracy of the reported data. Methods. Retrospectively
analyzing the reported mortality data of a 3-grade hospital in 2011.
Results. There are 521 cases of death. The highest percentage of disease
diagnosis is symptoms or signs, followed by various failures. The main
reasons for the fill-in error in the death medical certificates are that the
fundamental concept of the cause of death is not clear and the cause of
death chain fill is not standard. Conclusion. The judgment of the root cause
of death is the key factor that influences the quality of the medical death
certificate. Effective death monitoring management mode and enhancing
the cause of death monitoring talent ability construction can effectively
improve the quality of filling in.
Key words: Death medical certificate; Root cause of death; Death chain
The death management of population is a fundamental task for managing
the cause of death, the death level and the change in rules thereof; the death
management plays a very important role in establishing social and economic
development plan, and health service development plan and in estimating the
health level of people and social health status. Meanwhile, the death manage-
ment also provides the basic data for scientific researches on medical science,
demography and so on, and has important social and economic significance
in addition to scientific value. Death Medical Certificate is issued by National
Ministry of Health and is applicable nationwide. The certificate on resident
death and its cause certified by the health and medical department is a source
of basic information on the vital statistics and demographic statistics related
work and is a fundamental legal basis for judging the characteristics of death.
In our country, the death case direct network report is initiated by Chinese
Centre for Disease Control and Prevention and its purpose is to improve
the early warning capability of the disease monitoring system, so the accu-
racy of the death case disease information may influence the early warning
capability of the monitoring system [1].
1. Data source and methods
1.1 Data Source Surveying 521 death medical certificates filled in in 2011.
1.2 Methods Analyzing problems in every certificate, recording and
counting via excel, discovering problems and correcting in time.
2. Results
Among 521 death medical certificates obtained throughout the year, 189 death
medical certificates were not filled in according to the required standard and
the percentage of unqualified certificates is 36%, wherein the certificates of
nonstandard writing of death cause are 154, amounting to 332 errors in total
(Tables 1 and 2). Various error types are analyzed as below.
14

Table 1. Problem analysis of death medical certificates.
Proportion in yearly
Defect type Copies
Delay(more than 7 days) 7 1.34
Survey record of unfilled items 12
Unfilled time interval from onset to death 25
Leaked and wrong basic items (registered 25
address, profession and job type,
ID card number)
Nonstandard fills of death cause 154
3. Cause analysis
3.1 The training of personnel is incomplete. Insuf-
ficient understanding of the importance of the filling
in of death certificate, easy ignorance of the quality of
filling in, especially incomplete training work organized
by hospitals and departments, indifference on pre-job
training of new entrants.
3.1.1 Confusion on conception of cause of death.
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The difference between the clinical understanding of the
cause of death and the root cause of death in necrology
results in that clinicians often do not fill in as per the
requirement of International Disease Classification [2].
In the filling in process, the diseases that directly cause
death and those that promote death are not clearly
distinguished and the concepts are confusing, so the
physicians must clearly distinguish the concepts of dis-
eases that cause death and those that promote death.
The definition of the root cause of death is ‘(a) earliest
disease or loss in a series of disease events for directly caus-
ing the death, or (b) the accident or violence causing fatal
damage’ [3].
3.1.2 Nonstandard filling in of other important
diseases. The causal relationship of diseases that cause
death is not clear and the disease chain is not reason-
able. Especially, the people belonging to an older age
group (especially old age) often have various diseases.
For example, the root cause of death a patient has filled
in is as follows: I (a) cirrhosis and uremia, (b) chronic
hepatitis and chronic nephritis. An analysis of this case
revealed that the direct cause of death of the patient is
Table 2. Nonstandard writings of death cause.
Constituent ratio
Item Number
Main disease diagnosis (please fill in the
specific disease name and do not
fill in symptoms and signs) first item
demanded to be filled in.
Unspecified position of tumor 1 0.30
Reverse causal relationship of death 5 1.51
Nonstandard disease diagnosis name 15
Unclear causes of injury or no injury 23
Non-corresponding complication 26
diagnosis and etiological diagnosis
Various failures 65
Symptoms or signs 76
Other important diseases irrelevant to 121
death and cause of death, the second
item to be filled in
Sum 332
www.informahealthcare.com/cmr
Analysis of death certificate reporting 15
uremia, but chronic nephritis has clearly a causal relation
with the direct cause of death, so cirrhosis and chronic
death cases (%) hepatitis can only be listed as item II rather than item I.
Under this condition, some physicians list multiple diag-
2.30 noses of the patient on the whole without analysis and
4.80
4.80 regardless of primary and secondary items, thus causing
the confusing logical relations among diseases.
3.2 Insufficient timeliness of network reporting.
29.56
A few physicians fail to fill in and report the certificate
within the prescribed seven days [4]. The death of a
patient may happen at any time during the duty period
of any one physician. Because the managing physician
is not on duty during the holiday time and the relative
of the patient fails to pay fees in time, the physician
on duty cannot fill in the certificate in time and hence
there is a delay in preparing the report [5]. On the other
hand, there is only one network-reporting professional
with no backup for direct-reporting workers, this being
another reason for reduction in the submission of timely
reports.
3.3 Insufficient supervision of network direct-
reporting personnel. The network direct-reporting
personnel has incomprehensive knowledge on many
professional clinical diagnoses. Even if the certificate is
reported in time, the quality of filling in is not guaran-
teed. Therefore, it is necessary to enhance the effective
supervision on filling in death certificates.
4. Improvement measures
4.1 Enhancing targeted trainings. All levels of doctors
in the entire hospital trains at least twice in the whole
year; especially, for the new graduates and postgradu-
ates, undergoing training is very important before start-
ing with their jobs. The training content includes the
basic writing standard, the method of reporting the
root cause of death and ICD-10 coding of Death Medi-
cal Certificate. Meanwhile, doctors must make full use
of their medical knowledge and accurately and scien-
tifically mention the correct medical terms for diseases .
Doctors should know very well about the specific provi-
sion available for reporting the root cause of death; all
failures, shock and sudden death cannot be filled in as
the root cause of death. Through training, the filling in
of death cause (%) accuracy of the death cause chain is raised to 70.23% in
July 2012 from 60.24% in January 2012, and the selection
accuracy of the root cause of death is raised to 75.98% in
July 2012 from 70.01% in January 2012. In the compari-
son made before and after the training, it has been found
that the filling in accuracy of the death cause chain and
4.52
6.92
the selection accuracy of the root cause of death are on
7.82 the rising trend, and the magnitude of the error rate of
various failures has steeply declined.
19.58
22.90
4.2 Defining the filling in and reporting system of
36.45 ‘death certificate’. The special cases should be clearly
stipulated; for example, the duty physician is required
100
to fill in the Death Medical Certificate as soon as the
patient dies and if the patient fails to clear the fees, the
 16 Liu Fang et al.
network direct-reporting personnel needs to be finished
first; after the fees are cleared, the managing physician
stores and gives the related parts of Death Medical
Certificate to the relative of the patient. Then the related
parts are uniformly submitted along with the medical
record via an auditing and clearing office on the normal
working day. Death Medical Certificate is a legal instru-
ment, so the person responsible must be strictly speci-
fied; and only doctors with national practicing doctors’
qualification are qualified to fill in the certificates.
4.3 Defining the responsibility of death network
direct-reporting professional. The death network
direct-reporting professional should seriously audit
the reported death medical certificate and urge for
improvement; and the death network direct-reporting
professional should regularly attend the trainings of
epidemiology and health statistics, international statis-
tical classification standard of diseases and other related
knowledge. Meanwhile, one additional death network-
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reporting professional should be added so as to ensure
the work continuity and reporting timeliness.
4.4 Giving great impetus to death survey work.
For the death cases before emergency treatment, many
patients died at home; their relatives were from rural
areas and lacked medical knowledge, so the death survey
work could not be carried out which resulted in some
missed-out items. To eliminate the missed-out survey
content, the local communities conjointly strengthened
the popularization of medical knowledge. It is very
important to know the health status of residents in juris-
dictions.
4.5 Evaluating quality. The reported data about
causes of death are comprehensively evaluated and
are reported quarterly. The evaluation content com-
prises three aspects: data quality, underreporting and
reporting timeliness, and the statistical data, which are
publicly displayed on the medical quality bulletin. The
comprehensive quality evaluation promotes the qualita-
tive management to the level of quantitative manage-
ment and accurately finds out problems, and evaluates
and corrects them. The present focus is on improving
the selection accuracy of the root cause of death, and the
right selection of the root cause of death will be taken as
an important index of the quality evaluation.
4.6 Rewards and punishments. The data audit of
the cause of death is key point to ensure the data qual-
ity. Delayed reporting, underreporting and filling errors
are counted; the quality analysis report is done monthly
and is reported to the quality management division; the
quality control deduction is carried out in the economic
management accounts of divisions and individuals; at
the same time, the divisions having qualified filled-in
reports should be rewarded.
References
[1] Xu Haiying . Death Reporting Card Management Status Survey
and Countermeasures . Chinese Medical Record, 2007,8(4):
34–35.
[2] Pan Xiliu, Chen Aijuan. Talking on Problems in Filling Resident
Death Medical Certificate. Journal of Navy Medicine, 2006,
27(3):249–250.
[3] Peking Union Medical College Hospital World Health Organization
Cooperation Center of Disease Classification, compilation.
International Statistical Classification of Diseases and Related
Health Problems . The Second Volume of the Tenth Revision.
Beijing: People’s Medical Publishing House, 1996:20.
[4] Wei Lina. Problems in Death Network Reports and Counter-
measures . Chinese Medical Record, 2011,12(9):16–17.
[5] Liu Xiaoyan, Ji Ping . Methods of Improving Medical Death
Certificate Filling Quality. Chinese Medical Record, 2011,
12(1):24–25.
Copyright © 2013 Editorial Board of Chinese Medical Records