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Check for goofs...
Before finalizing, be sure you documented all required information in Epic.
Also be sure of the following:
♦ I entered the correct date and time of death, indicating when death was pronounced by examination or in the case of brain death by testing.
♦ I determined this was NOT a case accepted by the Medical Examiner because if it was, the ME will complete the death certificate, not me.
♦ I used no abbreviations on the death certificate!
♦ In Part I, I listed only ONE condition per line.
♦ I didn't enter a mode of dying as the cause of death. Example of mode ⇒ cardiac arrest.
♦ I was specific about the cause of death. For example - cancer of sigmoid colon rather than bowel cancer; left-sided pneumonia rather than pneumonia.
♦ I reported the cause of death in a chronological manner so it clearly states the events that led up to the death. I reported the final complication or condition on the top line.
♦ Causes of death are related; each cause reported caused what is on the line above it.
♦ I didn't lose sight of the underlying cause of the patient's problems. For example, rather than urinary tract infection as the underlying cause, was it urinary tract infection due to indwelling catheter due neurogenic bladder due to multiple sclerosis.
Certify the Death in the MA Electronic Death Registration System (EDRS)
When you are notified that the death certificate is ready to be certified, log into the EDRS system, review the data that was entered in the medical certifier tabs and then certify the death.
When you certify, you are attesting to the fact that the person died due to the causes listed.
Click here to log into the Massachusetts Electronic Death Registration System.
The steps to certify are:
Log into your VIP EDRS account.
Your name will appear on the screen ⇒click on your name.
For the patient assigned to you ⇒ click on "process"
On the first screen that opens ⇒ click on "continue"
On the next screen ⇒click on "Tab 12 - Record Action"
On the same screen ⇒click on "Certify" in the middle left side of the screen
On the same screen ⇒ click on "Finish" at the bottom of the screen
When you click on Finish, a warning screen will appear. On that screen ⇒click on "Save As Pending"
Info for families
Next step for the family: Usually it's to contact funeral home of choice. They will assist with arrangements. Funeral home will need family to sign a release to authorize release of body from hospital to funeral home.
Obtain Copies of Death Certificate:
For Medical Examiner Cases, go to https://www.mass.gov/death-certificates
For NON-Medical Examiner Cases, go to https://www.mass.gov/how-to/request-a-death-certificate or contact city/town clerk where death occurred. The funeral home will usually assist with obtaining death certificates for families.
Hospital Autopsy Reports: Usually available in 30-60 days. Become part of the Decedent's MR. Administrator/executor of estate can contact HIM for copy of final report. HIM - 508-334-5700, press 1 and then 2.
Medical Examiner Autopsy Results: Online request - https://www.mass.gov/how-to/request-a-copy-of-an-autopsy-report or call Office of the Chief Medical Examiner, Boston at (617) 267-6767.
Document in Epic
Enter Information in Epic
Document information about the patient's death in the Epic Discharge as Deceased Navigator. The information is used to generate the death certificate.
For brain death/potential organ donation: Refer to the Job Aid (Workflow for Brain Death to Organ Donation) posted on Epic Central for specifics of how to document in this situation.
To document the death in the Discharge as Deceased Navigator:
Go to the Epic encounter during which the patient died.
Click on discharge ⇒left tool bar.
Click on discharge as deceased ⇒ top tool bar.
The navigator has several sections and ALL sections must be completed (even if it doesn't seem to apply - for example, if the death is not reportable to the Medical Examiner, you must check not reportable).
When all sections are completed, the information will provide PAS - Admitting with a report of the death. The report will have the information you entered ⇒ all of which is needed for the death certificate.
PAS - Admitting staff will do data entry for you, completing the Medical Certifier tabs of the death certificate in the MA Electronic Death Registration System (EDRS).
You will be notified when the death certificate is ready to be certified.
Follow directions that follow on the CERTIFY page.
Cause of Death
Reporting Cause of Death can be tricky! Here's help...
Cause of Death should be reported in a way that provides the best possible explanation of WHY the person died.
Not so easy! So here are some tips:
When completing the cause-of-death section, think of it this way:
a. Most recent condition (due to)
b. An older condition (due to)
c. An even older condition (due to)
d. Oldest condition that started it all
Part II. Significant conditions that contributed to but did not directly cause the death
1. No abbreviations!
2. No mode of dying! Frequent mistake so please read! What is a mode of dying? Something that tells you that the patient died, not what caused the death. Cardiac arrest, asystole, cardiopulmonary arrest, cardiopulmonary cessation, etc. are modes of dying. By avoiding such terms, the lines can be preserved for reporting conditions that convey useful mortality information. Remember, NO mode of dying!
3. One cause per line in Part I. When reporting immediate, intermediate and underlying causes of death, list only one cause per line.
4. Be as specific as possible when reporting cause.
5. Intervals indicate the time from onset of a condition to time of death. Again, be as specific as possible and list in chronological order, most recent onset on first line to longest interval on last line.
6. Don't forget to report conditions that contributed to the death, but didn't directly cause the death.
To Report Cause of Death:
ON LINE 1: Report the immediate cause of death. That's the final complication or condition directly causing the death. Avoid listing organ failures such as respiratory failure, renal failure, etc. and if you do, provide additional information about the etiology on the line below. Be as specific as possible. And remember, don't report mode of dying such as cardiac arrest.
ON NEXT LINE(S): Report the intermediate cause of death on the next line or lines. This is what preceded and caused the condition reported on the line above it. You can list just one intermediate cause of death or use more lines to report more than one. Remember, each condition you list caused the condition on the line above.
ON LAST LINE: Now report the underlying cause of death. That's what started it all. The underlying cause might be present for years.
Next, list other significant conditions that contributed to the death, but did not directly cause it. You may list more than one condition per line in this section.
Uncertainty: Qualifiers such as probable, presumed may be used. For example, "probable myocardial infarction."
No probable cause in elderly: When an elderly patient dies and there is no probable cause of death, avoid terms such as senescence, infirmity, advanced age. Acceptable to report as "undetermined natural cause."
Best medical opinion: The reported cause of death is the best medical opinion of the certifier.
Click here for sample cause of death reporting from the CDC
Time of Death
How is time of death determined?
1) For CARDIOPULMONARY DEATHS, it's the date and time the examination was performed that determined death occurred.
2) For BRAIN DEATH, it's the date and time that brain death was declared based on brain death testing.
3) For cases of BRAIN DEATH AND POTENTIAL ORGAN DONATION, the date and time of death are when brain death was declared based on brain death testing. The time of death is NOT when organ donation occurs.
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