Document Type : Original Article(s)

Authors

1 Lecture of Education of Medical Records, Mazandaran University of Medical Sciences, Mazandaran

2 Lecturer of Statistics, Azad University, Sari

3 Anesthesiologist, Assistant Professor, Mazandaran University of Medical Sciences, Mazandara

Abstract

Introduction: Death-related information is source for identifying the health prerequisites and formulating the related programs. Due to importance of data for decision making, evaluation of it to determine the rate of documentation and errors is necessary. Methods: In this descriptive, cross-sectional study, all issued certificates in 5 teaching hospitals of Mazandaran University of Medical Sciences during March 2004-2005 were reviewed. The characteristics of certifying and deceased and the documentation error were checked with a check list according to the WHO introduced death certificate and for associated factors a self administration questioner was used. The rate of documentation and errors calculated. Four types of error were classified. Error 1, only the mechanism(s) of death or mode of dying is given. Error 2, multiple causal sequences are given. Error 3, a single sequence is given but is not specific enough. Error 4, a single sequence is given but the order was incorrect. The questionnaire was designed according to aims of research and reliability was tested with Chronbach’s alpha = 0.87 in a pilot study. Data analyzed with SPSS software. Results: Documentation rate was 51 percent. In 137 (16.4 percent) death certificates cause of death was documented correctly. The error 3 was the most, (38.1 percent) and the error 2 has the lowest (3.4 percent) rate. According to the certifier opinion, the most significant factors associated with the error rates were related to inadequate equipment (35.2 percent) for determining the diagnosis such as autopsy, undiagnosed (22 percent), and nor teaching program for physicians with the documentation subject.Conclusion: Findings show that documentations in death certificate have problems. Training program in death certificate completion for physicians and improvement of diagnostic tests for better documentation are suggested. Keywords: Cause of Death; licensure; World Health Organization; Death.