MINISTRY OF HEALTH SOCIALIST REPUBLIC OF VIETNAM

Independence - Freedom - Happiness

Ref. No.: 1921/QĐ-BYT Ha Noi, 12nd, July 2022

 
DECISION
On promulgation of guideline for completing medical certificateione of cause
of death form in medical examination and treatment facilities

THE HEALTH MINISTER

Pursuant to the 2009 Law on Medical Examination and Treatment;
Pursuant to Decree No. 75/2017/ND-CP dated June 20, 2017 of the Government
defining the functions, tasks, powers and organizational structure of the Ministry of
Health;
Pursuant to Circular No. 24/2020/TT-BYT dated December 28, 2020 of the
Minister of Health, stipulating medical certificatemedical certificatione of cause of death
form, death notification form and mortality statistics in medical examination and
treatment facilities;
At the proposal of the Director General of Vietnam Administration of Medical
Services, Ministry of Health.

DECIDES:

Article 1. To promulgate together with this Decision Guideline for completing

ICD-10-based medical certificatemedical certificateion of cause of death form in
compliance with the Health Minister's Circular No. 24/2020/TT-BYT dated December
28, 2020 promulgating medical certificatemedical certificateion of cause of death form,
death notification form and mortality statistics in medical examination and treatment
facilities.
Article 2. This Decision takes effect from the date of signing.
Article 3. The Chief of Cabinet Office of the Ministry of Health, the Director
General of Vietnam Administration of Medical Services; The Director of Health
Insurance Department and the Directors of Departments and General
Departments/Administrations under the Ministry of Health, the Directors of Department
of Health of provinces and centrally-run cities and the Heads of the relevant units are
responsible for implementation of this Decision./.
Recipients: FOR HEALTH MINISTER
- As in Article 3; VICE HEALTH MINISTER
- Health Minister (for reporting);
- Vice Health Ministers (for directing);
- MOH Portal; (singed)
- Archived: Admin, Medical Services
Addministration.
Nguyen Truong Son
 
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 MINISTRY OF HEALTH SOCIALIST REPUBLIC OF VIETNAM
Independence - Freedom - Happiness

GUIDELINES
For completing Medical certificateione of cause of death
(Promulgated together with Decision No. …./QD-BYT dated dd…mm, 2022 of the
Minister of Health)

A. CONCEPTS OF DEATH AND CAUSE OF DEATH

1. Importance of cause-of-death data:
Cause-of-death data is an integral part of civil registration and vital statistics
(CRVS), and plays an important role in determining health priorities, formulating
national population and health policies, evaluating effectiveness of health
intervention programs and improving quality of diagnosis and treatment in medical
examination and treatment facilities.
2. Objectives
This guideline helps medical examination and treatment facilities to:
2.1 Understand correctly concepts of cause of death, underlying cause of
death and chain of events leading to death;
2.2 How to aAccurately and completely record data on medical
certificatemedical certificateion of cause of death (MCCD) form promulgated
together with Circular No. 24/2020/TT-BYT dated December 28, 2020, according
to World Health Organization (WHO) standards.
2.3 Ensure the quality of mortality recorded and reported by medical
examination and treatment facilities.
3. Concepts related to cause of death (COD)
3.1 Concept of death: Death (mortality) is the irreversible cessation of all
vital activities of a body including cardiac arrest, respiratory arrest and loss of
consciousness. It is necessary to differentiate between clinical death as the
termination but potentially reversible, and complete death as the decomposition of
tissues and cells of the whole body.
3.2 Cause of death: Defined as all those diseases, morbid conditions or
injuries which either resulted in or contributed to death and the circumstances of
the accident or violence which produced any such injuries. Cause of death is a
disease, injury, health condition, circumstances, accident, direct or indirect
poisoning leading to death:
Examples of causes of death: neonatal tetanus; stroke caused by brain
hemorrhageic brain; low birth weight; coronary artery disease; myocardial
infarction; asthma; birth asphyxia; snake bite; fall from height; traffic accident
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when riding a motorbike and or being hit by a car; being attacked with a sharp
object; deliberate poisoning with chemicals, etc.
3.3 Underlying cause of death):
- The disease, injury or event which is the onset of the train of events
leading directly to death, or the circumstances of the accident or violence which
produced the fatal injury.
- Underlying cause of death (also called root cause) is defined as the disease,
injury or event without which the patient would not have died.
Example 1: A patient who is was a pedestrian admitted to the hospital after
a traffic accident of being hit by a motorbike and diagnosed with a fracture of
femur fracture. Two hours later, the patient suffered fromprogressed to a
traumatic shock and died.
In thise example the underlying cause of death is “Traffic accident: a
pedestrian hit by a motorbike”. Statistics on the underlying causes of death help
develop health policies for early prevention of circumstances that cause fatal
injuries, diseases right from the community, for example: traffic accidents,
drowning, poisoning, suicide, cancer, diabetes, etc.
3.4 Immediate Intermediate cause of death:
- The medical condition which is closest to death before causing circulatory
arrest, respiratory arrest, brain death, for example: Septic shock; Traumatic shock;
Brain hemorrhage;
In Example 1, the immediate intermediate cause of death is “Traumatic
shock”. Doctors and medical staff in hospitals often get confused with the
immediate intermediate cause of death with the underlying cause of death.
3.5 Antecedent/intermediate/intervening cause(s) of death:
- The medical conditions, complications that occur between the underlying
cause of death and the immediate intermediate cause of death.
In example 1, “fracture of the femoral shaft” is an antecedent cause of
death between the underlying cause of death, “traffic accident: pedestrian hit by a
motorbike” and the immediate intermediate cause of death, “traumatic shock.”
Statistics on antecedent and immediate intermediate causes of death help
doctors and medical staff plan on management, treatment, and prevention of death
at medical facilities.
3.6 The sequence of events and diseases leading to death: is the sequence
of events and clinical courses of cause(s) of death arranged by time interval from
onset to death, with the principle of immediate intermediate cause of death (closest
to death) in the first place, and the underlying cause of death last, and the
antecedent cause(s) of death in the middle. In cases where there is only 1 one cause
of death, that is becomes the underlying cause of death; In cases where there are
multiple causes of death, the cause that initiates the sequence of events or diseases
leading to death is the underlying cause.
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 Example 02: The patient fell into the water, and was picked up in a state of
cyanosis, no breathing, and the on-the-spot emergency did not work and it was
concluded that the patient died.
Seq
Cause of death ICD-10 code Time interval
.
a Drowning (accidental)

Example 03: The patient was bitten by a viper, then the patient felt pain and
swelling. Admitted to the hospital in a condition of pain, swelling, and
bruising from of the foot to the left thigh. The patient was given antivenom
serum but did not help. After 2 days the patient died.
Seq. Cause of death ICD-10 code Time interval
a Bleeding 2 days
b Snake bite 2 days

Example 4: An infant died right after birth due to a prolonged labor by the
mother, leading to asphyxia at birth, resulting in a lack of oxygen to the
brain.
Seq
Cause of death ICD-10 code Time interval
.
Lack of oxygen to the
a
brainBrain hypoxia
b Birth asphyxia
c Prolonged labor

3.7 Risk factors, diseases, and causes contributing to death (contributary

causes)
- The circumstance, disease, health condition that increases the risk, or
complications but is not directly involved in the chain/sequence of fatal events:
alcoholism, chronic diseases such as diabetes, hypertension, chronic kidney failure,
etc.
3.8 Mode of death
- The manifestations of death: cardiac arrest, respiratory arrest, brain death,
etc.
Doctors should avoid reporting the mode(s) of dying on the MCCD. This
includes terms such as ‘cardiac arrest’, ‘respiratory arrest’ or ‘brain death’. It is
noted that determining COD should avoid recording the mode of death, rather it
should start with the medical condition before causing the mode of death such as
cardiac arrest, respiratory arrest, brain death.
3.9 Manner of death
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 - The legal factor, circumstance that creates cause of injury or disease
leading to death. There are five ways of determining mortality: disease (natural
course of illness, including age); accidents (living accidents, labor accidents);
suicide (intentional self-harm, intentional self-poisoning); murder homicide
(criminal), murder (not illegal)following legal intervention due to the performance
of official duties; or unspecified (in case of detecting a dead body, while the
manner of death cannot be determined).
The recording of COD as suicide is also relatedmay affect to the benefits of
some types of insurance.
3.10 Mechanism of death
- The pathological and physiological mechanism leading to a
intermediateimmediate cause of death: e.g.: cerebral infarction (due to) malignant
tumor (due to) radioactive contamination (due to) intentional poisoning (death
mechanism is cerebral infarction, and the manner of death is murderhomicide).
4. Medical certificateione of cause of death (MCCD) form
Issued together with Circular No. 24/2020/TT-BYT dated December 28,
2020 stipulating medical certificatemedical certificateion of cause of death form,
death notification form and mortality statistics in medical examination and
treatment facilities. It is a form prepared according to the guidelines of the World
Health Organization (WHO).
The content of MCCD form consists of 3 parts:
- Administrative data: the most significant items are age, sex, medical
facility, place of death: at medical facility, death on the way to medical
facility, prognosis of death: hospital discharge to go home or die at home.
- Frame A: Medical datae related to COD.
+ Part 1, Frame A: enter the chain of fatal events leading to death.
+ Part 2, Frame A: risk factors, diseases contributing to death.
- Frame B: Data related to death such as mode manner of death (legal),
additional information for death cases with external causes, maternal
death, infant death.
- In addition, for some specific causes of death, depending on statistical
purposes, it is necessary to record some additional information, for
example, for COVID-19 deaths, it is necessary to collect more
information about vaccination status, antiviral drugs used.
5. Reception of MCCD form: MCCD form is used for statistical purposes,
kept at medical facilities, reported to the governing body, not distributed to family
members. Do not use the data recorded in MCCD form to criticize or review the
responsibilities of doctors and medical staff.
B. INSTRUCTIONS FOR COMPLETING MCCD FORM
1. Instructions for completing Part 1, Frame A
- Frame A is an important frame referring to data about disease and sequence
of events directly leading to death.

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- Identify the causes, conditions forming sequence of events directly leading
to death and record in Part 1
- Determine health conditions and status contributing to death (not belonging
to events listed in Part 1) to record in Part 2
- Determine the time interval from onset of each event till death and record in
the time interval column
- Identify the ICD-10 codes appropriate for the medical condition, fatal event
and record in MCCD form
- Always start on line 1a for intermediate immediate cause/condition directly
leading to death
- If there are any causes other than causes recorded in line 1a, write them
down in line 1b, and information is always written consecutively in
successive lines. while dDo not leave blank lines betweenin-between 2 lines.
- The cause in the lowest line of the chain of events chain listed in Part 1 will
be the underlying cause of death
- In cases where clinical symptoms, laboratory tests, functional exploration
results or even autopsy findings cannot identify COD, the cause is noted
documented as ‘Unknown’.
2. Instructions for completing Part 2 - Frame A
- Fill in information about diseases/causes that are not listed in Part 1 but
contribute to death in Part 2, together with the time interval written in
brackets.
- This part is to record health conditions and status that are not in the chain of
events directly leading to death, but have contributed to death.
- In reality, there are many cases where a patient with multiple diseases in one
course of treatment, especially with elderly patients.
- Underlying diseases and diseases occurring within a treatment course but are
not included in the sequence of events listed in Part 1 will have to be
recorded in Part 2.
3. Steps to complete MCCD form
- Step 1: Determine the sequence of events leading to death and record in Part
1, Frame A:
- A sequence of events consisting of diseases, or events that are causally
related (the latter event is a consequence of the preceding event).
- Start with the intermediate immediate cause of death in the first line (Part
1a) and end with the underlying cause of death in the most lower line.
- Arrange in chronological order of onset of events and diseases.
Cause of death ICD-10 code Time interval
Part 1 a Myocardial Infarction
b Ischemic heart disease
Part 2

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 - Step 2: Determine the time interval from the onset of each event, disease
(cause of death) till the patient's death, and write in space next to the
corresponding cause and event leading to death respectively. The unit of
time interval can be years, months, days, hours, minutes. If the time of onset
is unknown or cannot be determined, write ‘unknown’. Do not leave this
column blank.
Cause of death ICD-10 code Time interval
Part 1 a Myocardial Infarction 1 hour
b Ischemic heart disease 5 years
Part 2

- Step 3: Identify important risk factors and diseases contributing to death;

and include the time interval from onset to death, and record in Part 2 Frame
A.
Cause of death ICD-10 code Time interval
Part 1 a Myocardial Infarction 1 hour
Chronic ischemic heart
b 5 years
disease
Part 2 Type 2 diabetes 12 years
- Step 4: Add information in Frame B if the patient died from external causes,
maternal death, infant death.

4. Some notices when completing MCCD form

- Only write one diagnosis/cause per lineDocument only one condition per
line
- Write clearly. Do not cross out
- Do not abbreviate Name of disease/diagnosis should be clearly written in
full
- Diagnostic information must be recorded completely with clear meaning
- Always check the accuracy of all information written on the MCCD form
- There is no need to record information such as test results or contents
unrelated to COD
- Find the appropriate ICD code, accept 3 digit-codes for mortality coding
- Identify the time intervaldiagnosis
5. Cause of death conclusion in Death notification form and medical
records can be written in ways as follows:
Intermediate Immediate causes of death – Antecedent cause(s) of death –
underlying cause of death / Risk factors - Comorbidities contributing to death
Example: Septic shock – Sepsis – pneumonia due to Covid-19
complications, Progressive respiratory failure / Obesity – Diabetes – Hypertension.
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 This recording type is optional, but diagnosis must show the root cause of
death (underlying cause), intermediate immediate cause of death, and antecedent
causes; risk factors, underlying diseases, related comorbidities, contributing to
death.
6. Instructions for recording specific CODs
6.1 Death caused by infectious and parasitic diseases
- Specify the causative agent, if any (ICD codes range B95-B98).
- In case the causative agent is unknown, record "unknown agent".
- Specify the infected anatomical structure, organ system. For example:
urinary tract infection, respiratory tract infection.

6.2. Death caused by tumor, cancer

For death cases due to tumor or cancer, record detailed information about the
tumor including:
- The anatomical location of the tumor
- Characteristics such as benign, malignant, carcinoma in situ, or unknown /
uncertain characteristics
- Primary or metastatic (if possible), even if the primary tumor was given ais
surgically removed surgery long before death
- Anatomical Pathology results (if any)

6.3. Death during pregnancy and maternal death

- In case where a woman died during pregnancy or within 42 days of
termination of pregnancy, it must be recorded in Frame B, regardless
whether the intermediate immediate cause of death is pregnancy-related or
not

6.4 Death caused by Hypertension

- For hypertensive-related deaths, specify whether hypertension is primary or
secondary to other conditions (e.g., chronic pyelonephritis).

6.5. Death caused by Diabetes

- Diabetes can be aan underlying cause of death, or just a risk factor for
another underlying cause of death. 
- As a general rule, if a patient died from complications of diabetes (e.g.,
diabetic nephropathy), record diabetes (type 1 or 2) as underlying cause of
death. 
- If the patient died from stroke or acute myocardial infarction, record
diabetes as a risk factor contributing to death in “Part 2-Frame A”

6.6 Death caused by injury, poisoning and external causes

- If external causes such as traffic accidents, poisoning, suicide, diseases
leading to death, always record external causes as the underlying cause of
death. 

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 - External causes should be described in as much detail as possible according
to ICD-10 classification.
- In case of suicide, the manner of suicide must be clearly stated.
- For underlying cause of death, it is necessary to fill in both Parts 2 and 3-
Frame B of MCCD form

6.7 Death due to surgery, procedure

- In case of death due to surgery or procedure, the name of the surgery and
procedure must be recorded along with the medical condition for which the
surgery or procedure has been indicated; e.g.: appendectomy for acute
appendicitis. 
- It is necessary to fill information in Frame B of the MCCD form

6.8 Cases with unspecified diagnosiscauses

- Minimize the use of terms for unspecified medical conditions or diagnoses
causes
- Symptoms and signs (e.g., chest pain, cough, and fever) are also considered
as unspecified diagnosiscauses.
- Do not write the mode of death on MCCD form, for example: circulatory
arrest, respiratory arrest, brain death.
- In recording elderly COD, such terms such as "senescence" or "senile death"
should be avoided and disease-causing fatality for the elderly should be
found.
- In case where there is not enough COD information, write “death of due to
unknown COD".

6.9 COVID-19 death

- Record detailed information: For COVID-19 deaths, the chain of causes
leading to death in "Part 1- Frame A" of MCCD form should be as specific
as possible.
- In cases where COVID-19 causes pneumonia and ARDS leading to death,
pneumonia, ARDS, and COVID-19 should be included in “Part 1- Frame
A”. Doctors should write as detailed as possible to serve diagnosis and
treatment of patients in the future.
- In case where the patient has chronic medical conditions, underlying
diseases, non-communicable diseases such as coronary heart disease,
chronic obstructive pulmonary disease (COPD) and diabetes or a disability,
those should be recorded in “Part 2” - Frame A" of the MCCD form. 
- Cases of traffic accident and stroke patients who later tested positive for
COVID-19 should not be recorded with COVID-19 as the underlying cause
of death.
7. For cases where the patient with a severe poor prognosis (request by the
family to take the patient home)requested to go home by the family
- The hospital discharge information clearly stating "Severe prognosis,
requested to go home" refers to cases of death prognosis, and the family
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 requests hospital discharge for the patient to die at home according to
cultural and spiritual factors; or in case where it is no longer possible to
treat, and hospital discharge request is made but it is confirmed that death is
unavoidable unless treatment is given; Collecting information of those cases
is for statistical purposes, planning and policy development. In additionally,
those information will be helpful for grassroot level in order to support the
ascertainment of cause of death for home deaths.

- The medical facility must also establish a sequence of events leading to a

serious illness that is likely to lead to death and identify the underlying cause
that started this sequence of events (similar to the underlying cause of death)
and completed the Data collection Form for “Poor prognosis” patients as
similar to in the case of the death patients; then reporting these cases in the
MCCD online case report system of MOH.

- The Data collection Form for “Poor prognosis” patients then needs to be
stored, managed with the medical records of those patients.
C. QUALITY CONTROL IN COMPLETING THE MCCD FORM
1. Quality check of completing the MCCD form
Should be applied to check for 5% or all, 1 score will be got if the criteria is met
Seq. Commonly found errors Fail Pass
1 Entering 2 or more causes of death on the same line (part
1)
2 Invalid underlying cause of death
3 Use of nonstandard acronyms/abbreviations
4 Bad Illegible handwriting which canno't be read
5 Incorrect/clinically improbable sequence of events
leading to death Inaccurate sequence of death events or
with no clinically relevant cause and consequence leading
to death (part I)
7 In case where death was due to external causes but the
cause of death is recorded as only injury or disease due to
external causes?
8 In case where death was due to external causes (accident /
violence / poisoning) but lack of detailed information
describing external causes (non-coding according to ICD-
10)? (detailsDetails of accident or violence including
intent and activity [e.g. only “Traffic Accident” instead of
“Pedestrian hit by car”, knife attack] and where the
accident happened)
9 In cases of death due to cancer but only disease or
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 complications of cancer were recorded.
10 In cases of death due to cancer, lack of detailed tumor
information (anatomical location, primary or metastatic,
nature, morphology)
11 Missing ICD-10 code
12 Choosing wrong ICD-10 code against COD recording
13 ICD-10 code is not detailed compared to COD recording
cause of death
14 Missing time interval from onset to death, or missing
time interval units (e.g. hour, day, month, year)
9. Invalid underlying causes of death:
- Functional, systemic, physical, or subclinical symptoms (e.g., fever, back
pain, headache, hepatomegaly, etc.)
- Antecedent/intermediate/intervening causes of death (e.g., sepsis, secondary
hypertension, alveolitis, pathologic fracture)
- Modes of death (e.g., cardiac arrest, respiratory arrest, anuria, organ failure)
- General group of diseases for which a specific cause of death cannot be
determined (e.g., cardiovascular disease, birth defects, etc.)
- Cause of death does not match with gender
D. PROCESS OF COMPLETING THE MCCD FORM
1. The last treatedment doctor is the person who sets up the sequence of
events and diseases leading to death, fills in the MCCD form according to
instructions, finds the ICD-10 code appropriate for each event, diagnoses
determines the underlying cause of death and at the same time completes the
medical record of death patients. In cases where COD has not been determined, it
can be made after the autopsy findings, or after the results of mortality audits.
2. The clinical nurse taking care of the patient in the final ward is the person
who checks the completeness of the MCCD form, and re-checks the ICD-10 codes
and the time interval filled in the MCCD form.
3. The administrative nurse in the final ward is the person who checks the
completeness and accuracy of the MCCD form before transferring the patient
medical records and the MCCD form to the General Planning Department.
4. The General Planning Department is responsible for synthesizing, urging,
inspecting, supervising and supporting departments to properly complete the
MCCD form, check the accuracy of ICD-10 codes for COD, and enter information
or link it to the Ministry of Health's COD management software.
5. Medical examination and treatment facilities needs to assign staff to be
full-time or part-time in charge of implementing the MCCD form, clinical coding
of COD and statistical reporting on COD;

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 6. Medical examination and treatment facilities should integrate the MCCD
form into the current Hospital information system which align with the data
standards by MOH, which can be interoperable/linkaged with information
standards API, XML, Json, FHIR…. with the MCCD online case report system of
MOH.
7. Medical examination and treatment facilities needs to assign staff to
responsible for: managing and use the account of the MOH’s MCCD online case
report system at hssk.kcb.vn; account registration can be at cdc.kcb@gmail.com.

Appendix 1- Valid underlying causes of death according to WHO guidelines

Appendix 2 - Invalid underlying causes of death
Appendix 3 – MCCD form
Appendix 4 - The Data collection Form for “Poor prognosis” patients

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