Vietnam: How to record the diagnosis of the cause of death? How to handle when the patient has a severe prognosis and the family members request for home treatment?
- How to record the diagnosis of the cause of death in Vietnam?
- What are the notes for recording the diagnosis of the cause of death in Vietnam?
- How to record the conclusion diagnosis of cause of death in Vietnam?
- How to handle when the patient has a severe prognosis and the family members request for home treatment in Vietnam?
How to record the diagnosis of the cause of death in Vietnam?
Pursuant to subsection 3, Section B of the Guidelines promulgated together with the Decision 1921/QD-BYT in 2022 of the Ministry of Health, there are instructions on the steps to record the diagnosis of the cause of death as follows:
- Step 1: Determine the sequence of events leading to death and record in Section 1, Part A:
+ Is a sequence of events consisting of a pathology, or events that are causally related (the latter event is a consequence of the previous event).
+ Begin with the Direct Cause of Death on the top line and end with the Primary Cause of Death on the bottom line.
+ Sort by chronological order of occurrence of event or pathological diagnosis: near-fatal event above, sequence initiation event at bottom.
- Step 2: Determine the time interval from the occurrence of each event, pathology (cause of death) to the patient's death, and write next to the cause and event causing death respectively. The unit of time can be year, month, day, hour, minute. If the time of onset is unknown, please specify "Unknown", do not leave blank.
- Step 3: Identify important risk factors and pathologies contributing to death, along with the time period from occurrence to death, and record in Section 2, Part A.
- Step 4: Add the information in Part B if the subject died from exogenous causes, maternal death, neonatal death.
Thus, the recording of the diagnosis of the cause of death is done according to the 4 steps guided as above.
Vietnam: How to record the diagnosis of the cause of death? How to handle when the patient has a severe prognosis and the family members request for home treatment?
What are the notes for recording the diagnosis of the cause of death in Vietnam?
Pursuant to subsection 4, Section B of the Guidelines promulgated together with Decision 1921/QD-BYT in 2022 of the Ministry of Health, there are instructions on what to note when recording the diagnosis of the cause of death as follows:
“B. INSTRUCTIONS FOR RECORDING CAUSE OF DEATH DIAGNOSIS
…
4. Some notes when recording the Death Cause Diagnosis Card:
- Only write one diagnosis/cause per line.
- Write clearly, do not cross out.
- Do not abbreviate, the name of the disease/diagnosis should be fully and clearly written.
- Diagnostic information must be recorded completely and clearly.
- Always check the accuracy of all information on the certificate.
- Do not record information such as test results or content unrelated to the diagnosis of the cause of death.
- Find the matching ICD-10 code, in death coding accept 3-digit codes.
- Determine the time period from occurrence of event, illness to death.
Thus, when recording the form of diagnosis of the cause of death, it is necessary to pay attention to the contents and information that have been guided as above.
How to record the conclusion diagnosis of cause of death in Vietnam?
Pursuant to subsection 5, Section B of the Guidelines promulgated together with the Decision 1921/QD-BYT in 2022 of the Ministry of Health, there are instructions on recording the diagnosis of the cause of death in the medical records and death notices as follows:
“B. INSTRUCTIONS FOR RECORDING CAUSE OF DEATH DIAGNOSIS
…
5. How to write conclusions Diagnose the cause of death in the death notice and medical record as follows:
Direct causes of death (due to, because of, complications of) Intermediate causes of death (due to, because of, complications of) Major causes of death (in patients) risk factors - Comorbidities contribute to mortality.
Main causes of death (cause, result, complications) Intermediate causes of death (cause, lead to, complications) Direct cause of death (in patients) Risk factors - Comorbidities contributing to death
Example: Septic shock (due to, due to, complications of) Sepsis (due to, due to, complications of) Pneumonia due to Covid-19 complications Progressive respiratory failure (in patients) Obesity - Urinary sugar - Increased blood pressure.
Characters can be used instead: (“→” instead of “cause, lead to, complication”; “←” replace “due, because, complication of”; “/” instead of “on person” sick".
This recording is not mandatory, but a cause of death diagnosis must be made in relation to the root cause of death (primary cause), immediate cause of death, and intermediate causes. time; risk factors, underlying diseases, related comorbidities, affecting mortality."
Accordingly, the conclusion of diagnosis of the cause of death in the death notice and medical records shall be made according to the above instructions.
It is not mandatory to record the cause of death according to the guidelines, but a cause of death diagnosis must show each relationship from primary cause, immediate cause of death, and intermediate causes.
How to handle when the patient has a severe prognosis and the family members request for home treatment in Vietnam?
Pursuant to subsection 7 Section B of the Guidelines issued together with the Decision 1921/QD-BYT in 2022 of the Ministry of Health, instructing how to handle the case of patients with severe prognosis, the family requests for home treatment as follows:
- The hospital discharge information clearly states "Severe prognosis, request for home treatment" to refer to cases of family death who request to die at home according to cultural, spiritual factors, or no longer able to treat, but Prognosis if asked about high risk of death. The collection of information of these cases to increase the coverage of data to serve statistical work, planning, policy development. In addition, it is also helpful for the primary health care provider to determine the cause when the patient dies at home.
- The medical facility must establish a chain of pathologies and events leading to the disease before the patient returns, which is likely to lead to death, and determine the main cause that initiates this sequence of events according to the corresponding rules. Similar to determining the main cause of death, fill in the information management form for critically ill patients as in the case of death patients; report on the cause of death management system of the Ministry of Health.
- Information management sheets for critically ill patients will be saved and destroyed along with the patient's medical records.
Accordingly, the handling of patients with severe prognosis and their families request for home treatment will be carried out according to the above guidance of the Ministry of Health.
LawNet
