City Health Information
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



When the death is electronically reported, the cause of death is reviewed at least twice: first by the automatic quality-control features of EVERS, and then by manual review at the Health Department Burial Desk. If cremation clearance is requested, the certificate will be reviewed by OCME. After the death has been registered, the Health Department reviews all certificates to identify underlying causes of death that would typically not occur without a preceding cause.

Electronic System Review

Before any death can be registered, EVERS automatically performs a validation check on the information entered. This built-in quality-control measure will provide a warning message if you entered an abbreviation or entered a mechanism of death instead of a cause, a cause that suggests the death resulted from an injury, a rare cause of death that is of public health concern, or a nonspecific intermediate cause with no underlying cause (see Box 3).
If any of these validations fail, the field will be highlighted in yellow (Figure 2) to alert you to the issue. A message explaining the reason for the failure will appear at the bottom of the screen. You must review your entry. After entering additional information or confirming that the existing entry is true and complete, you may validate the cause by clicking the override button, saving the override, and proceeding to certify the death. Note that the field will remain yellow after you've completed the entry or checked the override box. This will not prevent registration of the death.

Examples of entries that will fail validation checks if entered as the underlying cause of death (eg, the final condition reported in Part I) include:

  • Congestive heart failure, myocardial infarction, sepsis, gastrointestinal hemorrhage, pulmonary embolism: These do not occur without a precipitating event or condition and are therefore intermediate, not underlying, causes of death.
  • Sepsis, cerebrovascular accident, seizure: These conditions may indicate nonnatural causes. On the death certificate, document the etiologically specific natural cause (eg, seizures due to chronic idiopathic epilepsy).
  • Cerebral infarct: The terms "cerebral infarct," "cerebellar infarct," "brain stem infarct," and "spontaneous hemorrhage" are more specific and thus preferable to "cerebrovascular accident," but in all these situations, you must indicate the underlying etiology of the disease; for example, hypertension, arteriosclerotic cerebrovascular disease, or ruptured aneurysm. For infarcts due to an embolic vegetation or thrombus, include the underlying disease process, such as infective endocarditis due to intravenous drug abuse or degenerative valvular disease.
Manual Review

After the death certificate is submitted for registration, the Health Department Burial Desk reviews the cause of death to ensure that 1) a cause of death is provided rather than just a mechanism of death (see Box 3); 2) no abbreviations are used; and 3) cause of death does not suggest an injury and therefore is a potential OCME case. In any of these circumstances, the certificate will be rejected by the Burial Desk or the case will be referred to OCME and the medical provider or hospital staff will be notified or contacted.

Cremation Clearance

If cremation clearance is requested, OCME must review the cause of death to ensure that the death was natural and that cremation does not pose a risk of destroying forensic evidence. If OCME cannot determine that the death was natural from what is written on the death certificate, the cause of death is deemed "not etiologically specific" and OCME will contact the certifying medical provider to establish the etiology of the cause of death and rule out any nonnatural component. This may delay registration of deaths and disposition of the decedent's remains, affecting families and funeral homes. Completing the death certificate with as much detail as possible allows OCME to evaluate cremation clearance without an additional call to the care provider.

Cause of Death Query

After a death has been registered, the Health Department Bureau of Vital Statistics may contact the certifying medical provider if a cause of death appears to be missing the underlying cause. A certificate that lists pneumonia as the only information in the cause of death section would lead to a query because pneumonia is rarely fatal without other serious conditions, and usually there is another condition present that puts the decedent at risk for pneumonia, such as emphysema. The Health Department will ask the provider to review the medical record and add missing, additional, or corrected cause of death data within 5 business days by submitting a Cause of Death Query amendment electronically via EVERS.


Image of Figure 2