The quality of death records in the United States is generally poor because physicians are not well trained in filing these reports.[Cole SK. Accuracy of death certificates in neonatal deaths. Community Med. February 1989;11(1):1-8] Death certificates are problematic for several reasons.[Davis BR, Curb JD, Tung B, et al. Standardized physician preparation of death certificates. Control Clin Trials. June 1987;8(2):110-120] Unexpected deaths frequently occur outside the hospital. The cause of death may not be immediately obvious. There may be no one to provide information on the identity of the person who died. Occasionally, there may be a question of  criminal activity having been involved in the death.

The cause of death is the most important information on a death certificate, but it is generally the most  inadequate. Preferably, the causes of death that are  listed are codable from the International Classification of Disease. For many certificates, however, the actual  cause of death is not clear, let alone codable. Cardiac  arrest, for example, is a result of death, not a cause. A  death certificate may list cardiac arrest as the cause of death and respiratory arrest following shock as the  contributing cause, even though the patient actually died of a gunshot wound, terminal cancer, or heart disease. Ideally, the cause of death should reflect what  killed the patient, not what the terminal events were.