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December 2012 New York City Department of Health and Mental Hygiene Vol. 31(6):41-49
Improving Cause of Death Reporting: Update 2012
  • Accurate and detailed cause of death reporting is critical for disease surveillance, public health research, and forensic investigations.
  • Cause of death reporting requires:
    • Review of the medical record
    • Identification of all conditions and events leading or contributing to the death
    • Ordering the conditions and events in a medically probable sequence



There are 2 parts to the cause of death section: Part I captures the primary chain of events that led to death, and Part II is used to record other significant conditions that contributed or may have contributed to the death, but were not a part of the primary sequence in Part I.

Part I contains 4 fields (lines a through d) for the cause(s) of death:

  • Immediate cause (line a, Part I): the condition that directly preceded permanent cessation of cardiac activity, often the condition being managed at the time of death (eg, sepsis, congestive heart failure, pneumonia).
  • Intermediate cause(s): the conditions that resulted from the underlying cause of death and led to the immediate cause of death.
  • Underlying cause (the lowest completed line in Part I): the disease or condition that set off the chain of events leading to the immediate cause of death. The underlying cause did NOT result from another event or condition.

If necessary, you can include more than one cause on a line, linking them with the words "due to."

Part II is for documenting other conditions or events that contributed to or hastened the death, but did not cause or result from the conditions or events in Part I. These conditions are entered on a single line in order of importance.

Cause of death reporting requires a review of the medical record, identification of all conditions and events leading to the death, ordering the underlying cause and resulting conditions in Part I, and documenting contributing conditions and procedures. Begin by reviewing the patient's medical history and creating a list of conditions that contributed or possibly contributed to the patient's death. Use your best medical judgment to identify the conditions or events that led to the immediate cause of death, and order them in the sequence that makes the most medical sense in Part I (see Box 2). Include the best estimate of the time interval between each entry and the date of death. List any additional contributing conditions outside the main chain of events in Part II. Events in Part II do not need to be listed sequentially but in order of importance.

For example, if the immediate cause of death on Line a is organ system failure (eg, hepatic failure), use Line b to record the etiology of that condition (eg, hepatitis C). On Line c list the condition or event that led to the hepatitis C (eg, intravenous drug use), and so forth. Document the entire sequence. The underlying cause of death should be entered last, since it is the disease or condition that triggered the chain of events leading to the death. In Part II, document any conditions that may have "sped up" the chain of events or made treatment of the underlying cause difficult (eg, obesity, atherosclerotic heart disease, depression). Often the conditions in Part II are also candidates for the underlying cause, but the events in Part I were more responsible for the patient's death. Do not use abbreviations because multiple conditions may have the same abbreviation.

In Figure 1, rupture of the pericardium was the immediate cause of death, which occurred within minutes. The rupture was a consequence of an acute myocardial infarction that occurred approximately 6 days earlier. The acute myocardial infarction was a consequence of atherosclerotic coronary artery disease present for 5 years prior to the death, which in turn was a consequence of hypertension, a condition the patient had for 20 years prior to the death. The hypertension was not known to have a medical cause; therefore, essential hypertension is documented as the underlying cause of death. This patient also had a history of chronic obstructive pulmonary disease, which may have affected the heart and made him more susceptible to the myocardial infarction or less likely to recover from it. Chronic obstructive pulmonary disease is documented in Part II as a condition that may have contributed to the death, but was outside of the chain of events beginning with hypertension and ending with the rupture of the pericardium. See Box 2 for examples of correct sequencing of causes of death, and the Table for examples of incorrect and correct cause of death documentation.


  • A patient with a history of poorly controlled hypertension and a prior positive stress test dies of an acute myocardial infarction. The patient also has a history of smoking and elevated cholesterol.
    Part I: Line a: acute myocardial infarction;
    line b: atherosclerotic coronary artery disease;
    line c: essential hypertension.
    Part II: smoking and hypercholesterolemia
  • A patient with liver cirrhosis from chronic alcohol abuse dies of an upper gastrointestinal bleed.
    Part I: Line a: upper gastrointestinal bleed;
    line b: probable ruptured esophageal varices;
    line c: liver cirrhosis;
    line d: chronic alcohol abuse
  • A debilitated patient with a history of emphysema, hypertension, and multi-infarct dementia is hospitalized for community-acquired Klebsiella pneumonia and dies.
    Part I: Line a: community-acquired Klebsiella pneumonia;
    line b: emphysema;
    line c: smoking.
    Part II: Multi-infarct dementia, atherosclerotic cerebrovascular disease, hypertension

PDF version of Box 2


Image of Figure 1

PDF version of Figure 1


Cause of Death Approximate Interval to Onset of Death Cause of Death Approximate Interval to Onset of Death
a. Upper gastrointestinal hemorrhage 1 day a. Upper gastrointestinal hemorrhage 1 day
b.   b. Presumed peptic ulcer disease 7 years
c.   c.  
PROBLEM: Cause of death is incomplete. Upper gastrointestinal hemorrhage does not usually occur without a precipitating event or condition and therefore cannot be the underlying cause. SOLUTION: Consider the patient's medical history. Based on a previous prescription history, peptic ulcer entered as underlying cause. "Presumed" is acceptable for unconfirmed diagnosis.

Cause of Death Approximate Interval to Onset of Death Cause of Death Approximate Interval to Onset of Death
a. Congestive heart failure 7 months a. Congestive heart failure 7 months
b. Atherosclerotic heart disease 4 years b. Atherosclerotic heart disease 4 years
c. Metastatic adenocarcinoma of the left breast   Part II. Other significant conditions: metastatic adenocarcinoma of the left breast
PROBLEM: Incorrect sequence: b does not arise from c. SOLUTION: Select the underlying cause that you believe ultimately led to the death. In this example, cancer of the breast is recorded in Other significant conditions.

PDF version of Table



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