8/9/2019 23. Icd, Certification of Causes of Death (Mhs) http://slidepdf.com/reader/full/23-icd-certification-of-causes-of-death-mhs 1/28 30/04/10 ICD, CERTIFICATION OF CAUSES OF DEATH, AND MEDICAL RECORD LECTURE 23 H. Moch. Harris Suhamihardja, dr., MPH.
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8/9/2019 23. Icd, Certification of Causes of Death (Mhs)
The development of public health, especially in the eld ofhealth management, health care, and research, broughtabout the need and opportunity to collect and compare largeamounts of data of high quality.
The use of ICD as the basic format has contributed to thecomparability between data collection systems.
Determination of disease-speci c death rates depends onaccurate completion of death certi cates. It is, therefore,essential that doctors completion the certi cation of deathcorrectly
8/9/2019 23. Icd, Certification of Causes of Death (Mhs)
For individual doctors to be able to monitor the progress oftheir patients and to decide on the best treatment forparticular diseases, they need information (recordedexperiences) on ho the symptoms of former and present
patients have responded to the treatments given!"atients# medical records should provide information forboth purposes$ as communication vehicle for the healthpersonnel involved in the care of patients and as a source
of administrative data!%herefore, each hospital, clinic, outpatient department,and other health institution, needs to &eep ade'uatemedical records for all inpatients and outpatients
8/9/2019 23. Icd, Certification of Causes of Death (Mhs)
statistical classification of disease and in ury ill depend,therefore, on the use to be made of the statistics to becompiled! d ustments must be made to meet the variedre'uirements of vital statistics offices, hospitals of differenttypes, medical services of the armed forces, socialinsurance organi*ations, sic&ness surveys, and numerousother agencies! +hile no single classification ill fit all the
speciali*ed needs, it should provide a common basis ofclassification for general statistical use$ that is storage ,retrieval , and tabulation of data!
statistical classification of disease must be confined to a
limited number of categories that encompass the entirerange of morbid conditions! %he categories should bechosen so that they ill facilitate the statistical study ofdisease phenomena!
8/9/2019 23. Icd, Certification of Causes of Death (Mhs)
n order to ma&e accurate comparisons of morbidity/mortalitydata, specified for various diseases/causes of death, it isessential that a uniform classification is used throught the
orld! -uch a classification as introduced many years ago,and is &no n as the nternational .lassification of iseases( . )!
-ince its inception, it has been revised about once every 10years the latest revision as adopted by ! +orld2ealth ssembly in
8/9/2019 23. Icd, Certification of Causes of Death (Mhs)
%here are t o supplementary classification $%he 5 code for classifying external causes of in uryand poisoning (for example, motor vehicle,accident, fall, fire)
%he 6 code for classifying reasons for contact ithmedical care and other factors influencing healthstatus, other than current diseases or in uries!
For single cause tabulation of the underlying causeof death, ho ever, the 5 code ould be used as theprimary code if, and only if, the morbid condition isclassifiable to .hapter 86 !
8/9/2019 23. Icd, Certification of Causes of Death (Mhs)
%hree digits codes ranging from 001 to 00; are given to thedisease categories!
5xample$ 0 1 <abies
0 : 7umps
0 3 =rnithosis
-ome changes in classification in successive revisions have
left gaps in the numbering system! %hese gaps have beenleft unfilled in order to avoid unnecessary changes in codenumbers familiar to coders ho have been using earlierrevisions!
8/9/2019 23. Icd, Certification of Causes of Death (Mhs)
fourth digit (after a decimal point) provides a greaterdetail, here necessary, ithin a three9digit category! %hefourth digit ill not normally need to be used in statisticaltabulations or reporting, but some sub9groups may beparticularly relevant in a particular country or in aparticular context, e!g!, a hospital diagnostic index
5xample$ 0 :!0 7umps orchitis
0 :!1 7umps meningitis
0 :!: 7umps encephalitis
=ptional fifth digit are provided in certain places, toindicate for example
8/9/2019 23. Icd, Certification of Causes of Death (Mhs)
%he causes of death to be entered on the medicalcertificate of cause of death are$
“all those diseases, morbid conditions or injurieswhich either resulted in or contributed to death andthe circumstances of the accident or violence which
produced any such injuries”
%his definition does not include symptoms andmodes of dying, such as heart failure, asthenia, etc!
8/9/2019 23. Icd, Certification of Causes of Death (Mhs)
The medical certi cate of death is designed toelicit the information that will facilitate theselection of the underlying cause of deathwhen two or more causes are #ointly recorded
8/9/2019 23. Icd, Certification of Causes of Death (Mhs)
Identi cation data 6ealth care institutions are comple organi7ationswith medical, nursing, technical, clerical and othersta2 caring for the patients. It is essential that theright treatment be given to the right person by theappropriate member of the treatment team.
8/9/2019 23. Icd, Certification of Causes of Death (Mhs)
%he data elements from the medical record re'uired fornational, regional and local records, include$
9 sex9 age9 marital status9 separation (final or discharge) diagnosis ( . codes)9 accident cause ( . code)9 operations ( ."7 code)9 number of days of stay in hospital (for inpatients)
8/9/2019 23. Icd, Certification of Causes of Death (Mhs)
ncorrect information in medical records could lead to falseconclusions hen it is used! %he information may beincorrect, either because it as incorrectly recorded, or
because it as incorrectly coded, either by mista&e orthrough lac& of &no ledge! For example, a cler&responsible for coding may not properly understand thedifference bet een a malignant and benign tumor andmay use the rong code, thus giving a false pictureconcerning the tumor in 'uestion!
8/9/2019 23. Icd, Certification of Causes of Death (Mhs)
9atients should be assured that personal and privateinformation given to the health wor:er will remaincon dential. It is desirable, therefore, for each country tohave laws that enforce this rights of the patients.
Con dential information should be given only to those whoneed to :now. !aws, or local regulations, should ensurethat con dentiality is maintained by all such personnel andprovide for penalties for misuse of con dential information.If a patient1s personal data need to be published in areport, the identifying information should be given incoded format, unless permission is granted by the patientto publish detailed identi cation data.
8/9/2019 23. Icd, Certification of Causes of Death (Mhs)