MEDICAL CERTIFICATION of CAUSE of DEATH

Death is so fi nal, whereas Life is full of possibilities

Warm Greetings of Peace and Hope

for the eventual
Redemption and Healing of the Land!
Jose Edgar V. Alonso April 30, 2025 08:52:47 PM

Department of Health, Philippines

MEDICAL CERTIFICATION of CAUSE of DEATH

Department of Health, Philippines

MEDICAL CERTIFICATION of CAUSE of DEATH
Session
3:
General Guidelines on
Medical Certification of Death

(Accomplishing MCCOD in Municipal Form

103 & 103A)

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MEDICAL CERTIFICATION of CAUSE of DEATH

Session Objectives
Define death, maternal and fetal deaths
Familiarize with Death Certificate
Form 103 and 103A
Differentiate the underlying, antecedent,
and immediate causes of death and their
corresponding guidelines.
Discuss ill-defined causes of death, mode of dying,
mechanistic terminal events and other garbage
codes.

Department of Health, Philippines

MEDICAL CERTIFICATION of CAUSE of DEATH

What is death?

 Permanent disappearance of all

evidence of life or all vital functions

 any time after live birth has taken

place

 without capability of resuscitation

Source: RA 7170 Organ Donation Act of 1990

Department of Health, Philippines

MEDICAL CERTIFICATION of CAUSE of DEATH

Fetal death
● Death of a fetus prior to complete
expulsion of a product of conception

● irrespective of the period of

pregnancy

Department of Health, Philippines 6

MEDICAL CERTIFICATION of CAUSE of DEATH

Maternal death
 Death of a woman while pregnant or within 42

days of its termination, irrespective of

duration and site of pregnancy
 Death from any cause related to and / or

aggravated by the pregnancy or its

management
 Not from accidental or incidental causes

Department of Health, Philippines 7

MEDICAL CERTIFICATION of CAUSE of DEATH

Death Certificate in the Philippines

Municipal Form no. 103
CERTIFICATE OF DEATH
For those born alive and died

Municipal Form no. 103a

 CERTIFICATE OF FETAL DEATH
 For those born dead or stillbirth

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MEDICAL CERTIFICATION of CAUSE of DEATH

Municipal Form No. 103

(Front Portion)

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MEDICAL CERTIFICATION of CAUSE of DEATH

Department of Health, Philippines 10

MEDICAL CERTIFICATION of CAUSE of DEATH

Municipal Form No.

103
Section for children aged
0-7 days

(Back Portion)

Department of Health, Philippines 11

MEDICAL CERTIFICATION of CAUSE of DEATH

Department of Health, Philippines 12

MEDICAL CERTIFICATION of CAUSE of DEATH

Certificate of Fetal
Death
Form 103a

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MEDICAL CERTIFICATION of CAUSE of DEATH

Department of Health, Philippines 14

MEDICAL CERTIFICATION of CAUSE of DEATH
Medical certificate portion of the
COD Authorized personnel only!
 Entries to all items in this portion
MUST be filled in by the
ATTENDING PHYSICIAN (AP), or
the LOCAL HEALTH OFFICER (LHO)

Affix signature!
 As certifier of death, AP or LHO
must affix his/her signature in the
last item (item 22)

Department of Health, Philippines 15

MEDICAL CERTIFICATION of CAUSE of DEATH
Review of the Local Health Officer
COD ●T h e local health officer affixes
his/her signature after
thorough evaluation
●T h e local health officer signs
twice
if the deceased died without
medical attendance. First as the
certifier and the second as the
ínterviewer.

Department of Health, Philippines 16

MEDICAL CERTIFICATION of CAUSE of DEATH
The Causes of Death
When faced with the duty of certifying, determine whether

1. Death is reportable or not.

2. Another physician is more qualified to complete the certificate.

3. When another physician had previously seen and treated a

patient who died outside the hospital. This physician could
provide accurate causes of death…more qualified to certify the
death

Department of Health, Philippines 17

MEDICAL CERTIFICATION of CAUSE of DEATH
Death Registration Process

1. Review of Death Certificate Attending Medical

Doctor
2. Review of Death Certificate Local Health
Offi cer
3. Registration of Death Local Civil
Certificate Registry

Department of Health, Philippines

1
MEDICAL CERTIFICATION of CAUSE of DEATH

Physicians are expected to

use:

Department of Health, Philippines 19

MEDICAL CERTIFICATION of CAUSE of DEATH
Medical certificate portion: part 1

● Reported in ● One cause per line

● Most recent event on top
causal order except in the
antecedent cause

Department of Health, Philippines 20

MEDICAL CERTIFICATION of CAUSE of DEATH
Underlying cause of death

● The disease or injury ● Or the circumstances of ● If only one cause of

which initiated the the event or violence death is reported, it
train of morbid events which produced the must be the
leading to death
fatal injury * Underlying Cause.

Department of Health, Philippines 21

MEDICAL CERTIFICATION of CAUSE of DEATH
Underlying cause of death
▪ T h e MOST IMPORTANT entry in the Certificate of
Death
▪ Basis for Mortality Statistics,

▪ Basis for preventive public health program

Department of Health, Philippines 22

MEDICAL CERTIFICATION of CAUSE of DEATH
Underlying cause of death
 T h e MOST IMPORTANT entry in the Certificate of
Death
 If there are two underlying causes of death prioritize the
one with public health significance .
ex. Nicotine abuse over Chronic Bronchitis
● Nicotine Abuse oveí Chíonic
Bíonchitis

Department of Health, Philippines 23

 MEDICAL CERTIFICATION of CAUSE of DEATH
Immediate cause of
death

● Most recent condition ● Written on the top line of

before the
death, directly leads to death Certificate of Death

Department of Health, Philippines 24

MEDICAL CERTIFICATION of CAUSE of DEATH
Antecedent cause of
death

• Other intervening causes of death

• Occur between the immediate and underlying
causes
of death
• Written on the middle line of the certificate of
death
• May have two causes of death
Department of Health, Philippines 25
MEDICAL CERTIFICATION of CAUSE of DEATH

The Causes of
Death
Seldom is there a single “correct”
way of writing the cause of death.

There are erroneous, incomplete,

good, and better ways of writing
the cause/s of death.

Department of Health, Philippines 26

 Writing cause of death statement

20 b
Department of Health, Philippines
25
MEDICAL CERTIFICATION of CAUSE of DEATH
Writing cause of death statement: Part I
I. Immediate : (a) Cardiopulmonary arrest ;
Acute Pulmonary Congestion

Antecedent : (b) End Stage Renal Disease ;

Obstructive Uropathy

Underlying : (c) Health Care Acquired

Pneumonia; Peritoneal Carcinoma

Department of Health, Philippines

2
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MEDICAL CERTIFICATION of CAUSE of DEATH
Erroneous and better ways of death
certification a. Chronic Kidney Disease Stage 5
a. Cardiopulmonary arrest due to b. Obstructive Uropathy
c. Peritoneal Cancer, Mesothelioma
Acute Pulmonary Congestion due to
d. Acute Pulmonary Congestion
e. Health Care Acquired Klebsiella
b. End Stage Renal Disease due to
Pneumonia
Obstructive Uropathy due to f. Peritoneal Carcinoma, histopath
unknown
c. Health Care Acquired Pneumonia g. Acute Pulmonary Congestion
due to Peritoneal Carcinoma h. Chronic Kidney Disease Stage 4;
Obstructive Uropathy
c. Peritoneal Carcinoma
Mesothelioma
Department of Health, Philippines
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MEDICAL CERTIFICATION of CAUSE of DEATH
Interval between onset and
death

● Often estimated ● “Unknown” or “approximate”

is acceptable if such is the
case

Department of Health, Philippines 30

MEDICAL CERTIFICATION of CAUSE of DEATH
Interval between onset and
death
Underlying Antecedent Immediate
• Occuííed • Occuís afteí the • latest condition
eaíliest oí undeílying but that
ÏIRSľ befoíe diíectly íesulted to
immediate death
Longest causes
Time between the Shortest
time immediate and under- time
interval lying intervals interval

Department of Health, Philippines 31

MEDICAL CERTIFICATION of CAUSE of DEATH
Interval Determination
Patient has symptoms of disease A for 3 days before
hospitalization, developed to disease B, on the second hospital
day. After 1 day, she got worse to disease C and died after 4
hours

3 days befoíe hospital then 2 days then 1 day then 4

a. Death
houís then 4 houís/moíe than 4
Disease C houís
1
b. day
6 days/moíe than 5
Disease B
days
c.
Department of Health, Philippines
Disease 3
0
MEDICAL CERTIFICATION of CAUSE of DEATH
Medical certificate portion:
part II
Contains causes of death that couldn’t be stated in
Part I due to rules like limited cause of death per
line or an ill defined cause of death.

● All other significant ● Does not directly lead to

factors or conditions the underlying cause of
present at the time of death
death *

Department of Health, Philippines 33

MEDICAL CERTIFICATION of CAUSE of DEATH
Intervals

range such as
seconds, minutes,
seconds to
hours, days, weeks,
minutes,
months, number of
minutes to hours,
years.
or
“known for five
- Validates that the causes of death are written in
years”
correct
sequence.

Department of Health, Philippines 34

MEDICAL CERTIFICATION of CAUSE of DEATH
C as e Sample 1 Causes of death with time interval

A 73-year old woman with known Alzheimer’s disease

for about 15 years had recurrent bouts of aspiration
pneumonia and finally died in a hospital after few
weeks.
Aspiration Pneumonia Weeks
Alzheimer’s Disease about 15 years

How many cause/s of death should be reported ?

Department of Health, Philippines 35

MEDICAL CERTIFICATION of CAUSE of DEATH
C a s e Sample 2 When there is only one reported cause of death
● A 56 year old man dies fíom acute
myocardial infarction within 3 hours
from its onset. He did not have any
other illnesses.

Acute Myocardial Infarction 3 hours

Department of Health, Philippines 36

MEDICAL CERTIFICATION of CAUSE of DEATH
Case Sample 3 When there are two reported causes of
death
● A 56-year old person dies from abscess of the
lung (noted 5 days before death), which
resulted from lobar pneumonia of the left lung
due to Streptococcal infection, diagnosed 2
weeks ago.
Lung Abscess, Left 5 days
Community Acquired Lobar
2 weeks
Pneumonia, Streptococcus

Department of Health, Philippines 37

MEDICAL CERTIFICATION of CAUSE of DEATH
C as e Sample 4 When there are three reported causes of
death
A 32 year old man while crossing the road was
hit by a truck, and sustained multiple fractures
of both legs . He died from traumatic shock 5
hours after the accident .
Traumatic Shock 5 hours

Multiple Fractures of both legs 5 hours

Pedestrian Hit By Truck,
5 hours
while crossing the road
*

Department of Health, Philippines 38

MEDICAL CERTIFICATION of CAUSE of DEATH
C a s e Sample 5 When there are four reported causes of death

Traumatic Shock 1 hour

Liver laceration; Blunt abdominal 5 hours; 5
trauma hours
Jogger while crossing the
5 hours
road hit by a truck

Department of Health, Philippines 39

MEDICAL CERTIFICATION of CAUSE of DEATH
Medical certificate portion of the
COD
PLEASE TAKE NOTE
● Do not use medical symbols
such as T/C, R/O.
● Do not use abbíeviations. Th e
only accepted abbíeviations
aíe HIV , AIDS and COVID 19.
● No skipping of lines.
● Line (a) must always have an
entíy.
● No signs, symptoms, and
abnoímal clinical/
laboíatoíy findings.

Department of Health, Philippines 40

MEDICAL CERTIFICATION of CAUSE of DEATH

ILL- defined causes of death

 Under ICD-10, ...are vague
categories, conditions, signs,
symptoms, abnormal clinical &
lab findings
 Insufficiently detailed to be of
value for public health purposes
 As per AO 2020-0008, All causes of
death should be compliant with the
latest ICD standards.

Department of Health, Philippines 41

MEDICAL CERTIFICATION of CAUSE of DEATH

ILL- defined causes of

death

● mechanistic terminal
events
● garbage codes
● mode of dying

Department of Health, Philippines 42

MEDICAL CERTIFICATION of CAUSE of DEATH

Examples of Ill-defined causes of

death
Disseminated intravascular
disease Cardiovascular/ heart
disease: unspecified Ventricular
tachycardia
Pulmonary
edema
Volume
depletion
Department of Health, Philippines 43
Septicaemia
MEDICAL CERTIFICATION of CAUSE of DEATH
Ill- defined cause of death:
septicaemia
Post-
Staphyloc
appendecto Tuberculou
oc cus
my s
Dermatitis
peritonitis Meningiti
E. s
coli
Klebsiell Gangrene
a of
pneumon left foot
ia

Depaítment of Health, 44
Philippines
MEDICAL CERTIFICATION of CAUSE of DEATH
Mode of dying: heart
failure

Myocardi Diabetic
al Nephropat
infarctio hy
n
Disseminat Cardiac
ed primary laceration
small cell due to
carcinoma penetrati
of left lung ng stab
wound

Depaítment of Health, 44
Philippines
 MEDICAL CERTIFICATION of CAUSE of DEATH
Mechanistic terminal events
• Terminal pathophysiological or biochemical
derangements
• Common final pathways that explain how a cause
of death exerts its lethal effect
• Should NEVER be reported
▪Respiratory / Cardiac / in the COD
Cardiopulmonary Arrest
▪ Asystole
▪ Ventricular Fibrillation
▪ Electromechanical Dissociation
▪ Pulseless Electrical Activity( PEA)

Depaítment of Health, 45
Philippines
MEDICAL CERTIFICATION of CAUSE of DEATH

Garbage Codes
Asphyxia Multi-organ Failure Shock
Asthenia Heart /Cardiac Failure Syncope
Hepatic Failure Uremia
Exhaustion
Hepatorenal Failure Vasovaga
Cachexia Kidney Failure l
Debility Renal Failure Brain Inhibition
Failure Ventricular Vasovaga
Coma Failure l Attack

Depaítment of Health, 46
Philippines
MEDICAL CERTIFICATION of CAUSE of DEATH

Garbage codes do not provide

meaningful information about the fatal
disease, condition or injury.

Even if they have ICD-10 codes, NEVER

use ill-defined and garbage codes AS
UNDERLYING CAUSE OF DEATH

Depaítment of Health, 47
Philippines
MEDICAL CERTIFICATION of CAUSE of DEATH

General Guidelines
1. All causes of death should be compliant with the latest ICD
standards.
2. Never report signs and symptoms or abnormal laboratory
findings and mechanistic terminal events as a cause of death
as cause of death.
3. Record only one cause of death per line except in the
antecedentcause of death.
4. Line (a) must ALWAYS have an entry.
5. Always put the underlying cause of death on the lowest used line
in Part I.
6. If the condition on line (a) resulted from another condition, put
this other condition on line (b), and so on, until the full sequence
is reported.

Depaítment of Health,
Philippines 4
MEDICAL CERTIFICATION of CAUSE of DEATH

General Guidelines
7. Conduct verbal autopsy in natural deaths with late
registration, without medical attendance, and dead on
arrivalwithout medical records
8. Use the current form of Certificate of Death or Certificate of
Fetal Death.
9. Complete each item legibly.
10. Do not make changes or alterations.
11. Use a pen with permanent black ink for signatures.
12. Do not use abbreviations or symbols.

Depaítment of Health,
Philippines 4
Depaítment of Health, 5
Philippines 0
 Any
questions?
Q & A Link:
bit.ly/mccodqa

Depaítment of Health, 5
Philippines 1
Daghang Salamat