P Pinto Pastor1, A Santiago-Saéz2, C Guijarro-Castro3, E Dorado Fernández4, E Albarrán Juan5. 1. Departamento de Medicina Legal, Universidad Complutense de Madrid, Madrid, España; Medicina Forense, Juzgado de Móstoles, Móstoles, Madrid, España. Electronic address: pilarpinto@ucm.es. 2. Departamento de Medicina Legal, Universidad Complutense de Madrid, Madrid, España; Servicio de Medicina Legal Intrahospitalaria, Hospital Clínico San Carlos, Madrid, España. 3. Departamento de Neurología, Hospital Virgen de la Luz, Cuenca, España; Coordinación del Grupo de Humanidades e Historia de la Neurología, Sociedad Española de Neurología, España. 4. Departamento de Medicina Legal, Universidad Complutense de Madrid, Madrid, España; Medicina Forense, Juzgados de Plaza Castilla, Madrid, España. 5. Departamento de Medicina Legal, Universidad Complutense de Madrid, Madrid, España; Medicina de Atención Primaria, Móstoles, Madrid, España.
Abstract
BACKGROUND: The medical certificate of cause of death is a dual-purpose document: an official registration of an individual's death and a statistical analysis of the populational causes of death. However, the completion of this document in clinical practice creates significant conflicts. OBJECTIVES: To analyse the completion and detect the main errors that occur when filling in these documents. We then compared the most important variables between the various types of documents analysed. MATERIAL AND METHODS: We conducted a descriptive cross-sectional study that analysed 513 certificates in the municipality of Madrid, Spain. The analysis included official documents (new and old versions) and hospital documents. RESULTS: The study's main finding was that 316 documents employed the term "cardiopulmonary arrest" as the immediate cause of death. In 98 other cases, other poorly defined immediate causes were listed. We were able to conclude that the hospital documents do not always have the required sections for the certificate to be legally functional. In the Professional Medical Association certificates, there is poorer completion of the current document because the document itself hinders its appropriate completion and requires better physician training to complete. CONCLUSIONS: We propose possible improvements to the official document so that it meets the legal requirements, facilitates its completion and fulfils its function. We also offer recommendations for hospitals that have their own document and suggestions for improving its completion.
BACKGROUND: The medical certificate of cause of death is a dual-purpose document: an official registration of an individual's death and a statistical analysis of the populational causes of death. However, the completion of this document in clinical practice creates significant conflicts. OBJECTIVES: To analyse the completion and detect the main errors that occur when filling in these documents. We then compared the most important variables between the various types of documents analysed. MATERIAL AND METHODS: We conducted a descriptive cross-sectional study that analysed 513 certificates in the municipality of Madrid, Spain. The analysis included official documents (new and old versions) and hospital documents. RESULTS: The study's main finding was that 316 documents employed the term "cardiopulmonary arrest" as the immediate cause of death. In 98 other cases, other poorly defined immediate causes were listed. We were able to conclude that the hospital documents do not always have the required sections for the certificate to be legally functional. In the Professional Medical Association certificates, there is poorer completion of the current document because the document itself hinders its appropriate completion and requires better physician training to complete. CONCLUSIONS: We propose possible improvements to the official document so that it meets the legal requirements, facilitates its completion and fulfils its function. We also offer recommendations for hospitals that have their own document and suggestions for improving its completion.
Keywords:
Causas de muerte; Causes of death; Certificado médico de defunción; Completion errors; Documentos medicolegales; Errores de cumplimentación; Medical certificate of cause of death; Medical-legal documents