Journal of Modern Medical

Introduction
Adeath certificate is a document that declares the identity, direct cause, intermediate cause, and underlying cause of a person’s death, which is completed, registered, and signed by a doctor who certifies death. If the information recorded in the death certificate is not correct, it leads to incorrect allocation of resources and problems in health planning. The World Health Organization (WHO) has provided rules and guidelines for the correct completion of the death certificate, choosing the underlying cause of death and how to code them. The underlying cause of death is a situation or incident that initiates the train of events leading to death, while the direct cause of death is the final complication or disease that directly caused death. According to the guidelines of the 10th edition of international classification of diseases (ICD-10), the underlying cause of death is used to code the causes of death. Since the information that can be extracted from death certificates is critical for policy making in basic research, epidemiologic studies, and public health service planning, it is necessary for the death certificate data to be complete and correct. Considering the importance of the correct completion of the death certificate and the resulting consequences, in this study, we aim to measure the level of compliance of the death certificate issued in Chamran Hospital in Ferdous, Iran with death coding rules of ICD-10, investigate the causes of non-compliance, and provide solutions to solve possible problems and improve the quality level of death information.

Methods
This descriptive cross-sectional and retrospective study was conducted on medical records of 97 patients who died in Chamran Hospital. To collect data, a researcher-made checklist was used, which includes information such as: case number, age, sex, duration of hospitalization, hospitalization department, direct and underlying causes of death mentioned in the death certificate, direct and underlying causes of death mentioned in the medical record, the time between hospitalization and death, and the expertise of the doctor issued the death certificate. It was completed by two researchers who had bachelor’s degrees in information technology. The exclusion criteria were the illegibility of the death certificate and the lack of access to the wanted information in the file. Out of 97 death cases in Shahid Chamran Hospital, 9 cases did not meet the criteria for inclusion in the study and were excluded from the review process. The death certificates were checked and corrected with the help of the expert in charge of coding, and the relevant information was extracted from the certificates and entered into the checklist. In the end, they were entered into SPSS software, version 16. Using descriptive statistics (percentage, frequency), the degree of compliance with the coding guidelines of ICD-10 for the codes registered in the medical records was measured.

Results
Most of the death cases (50%) were for the age group >80 years, while the lowest percentage (8.2%) was for the age group 20-40 years. The length of hospitalization for most of the deceased people (94.85%) was 1-20 days, and only for 4.12% of them it was 20-40 days. Moreover, the results showed that 64 patients died in the intensive care unit, 23 in the emergency department, 1 in the internal medicine department, 2 in the surgical department, 1 in the neonatal intensive care unit, and 2 in the cardiac intensive care unit, and 3 did not belong to a certain department. After examining the coding process in the medical records and comparing it with the coding guidelines of ICD-10, it was found that only 35(36.1%) files were coded correctly in accordance with the ICD-10 guidelines. In 53 cases (54.6%), the principles of selecting underlying causes of death and their coding were not observed. Therefore, the overall compliance rate was 36.1%, which is low compared to the studies in this field. Regarding the rate of compliance with general Principle (rules 1, 2 and 3) as well as the rules A to F, it was found out that the rate of compliance was 33% with general Principle, 4.1% with rule 1, 4.1% with rule 2, 5.2% with rule 3, 1.3% with rule A, 0% with rule B (trivial conditions), 1% with rule C, 1.2% with rule D, 0% with rule E, and 1.2% with rule F.

Discussion
Only 36.1% of the death records in the study hospital have correct coding, which indicates that the cording of the causes of death has unfavorable compliance with the standards of the WHO and ICD-10 coding rules. Based on the results, the most important challenge in choosing the underlying cause of death and assigning the correct code to the death certificate were the lack of considering the standard sequences defined by the WHO related to the underlying cause, direct, and intermediate causes by the doctors, not recording the time between the onset of symptoms and death, not having access to doctors after writing the death certificate, and not using smart systems to record deaths in hospitals and using a manual system instead which led to the failure to complete the correct death certificates and to use the correct process for choosing the underlying cause and coding the death certificate. Effective steps should be taken to reduce the errors related to the selection of the cause of death by providing regular and periodic trainings for doctors and coders about the rules for choosing the underlying cause of death. In addition, to have correct information about the death rate in Iran, registration systems should be designed more intelligently so that they do not accept absurd and ambiguous codes when registering, and use the “help” option to teach the rules and how to re-select. 

Ethical Considerations
Compliance with ethical guidelines
This study has an ethical approval from Birjand University of Medical Sciences (Code: IR.BUMS.REC.371.1398).

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions
Review and citations: Fatemeh Bahador; Data collection and writing: Zohreh Javanmard and Yousef Sadat; Data collection: Fatemeh Ameri; Data analysis: Azam Sabahi; Conceptualization, design, and writing: Hamideh Ehtesham.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors would like to thank the staff of Chamran and Hazrat-e Rasool hospitals for their cooperation.

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