In a news conference, Department of Health and Human Services Director Dr. Mandy Cohen said COVID-19 deaths are determined by medical examiners.
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Health officials said deaths are reported to the state in two ways: through laboratory-confirmed cases reported by hospitals and through death certificates.
In a written statement, a representative for the North Carolina Department of Health and Human Services said laboratory-confirmed deaths are reported by hospitals and physicians to local and state health departments, usually within hours or days of a patient's death. These deaths only include patients who previously tested positive for the novel coronavirus, which causes the disease COVID-19, and who died without fully recovering from the disease.
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The laboratory-confirmed deaths are the statistic reported on the NCDHHS website. To date, 213 laboratory-confirmed deaths have been reported across the state.
Additionally, health officials said they can source COVID-19 death counts from physician-completed death certificates, which indicate what the physician thinks may have caused a patient's death. NCDHHS said a patient does not need to have had a laboratory test for the novel coronavirus for a physician to list COVID-19 as their cause of death.
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"Because death certificates do not require a positive laboratory test, there will likely be many more deaths based on death certificate data than on laboratory data," the NCDHHS representative wrote.
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However, the representative said death certificates take time to process so that data may not be available until weeks after they are submitted.
Federal health officials have said they believe the current data on deaths in the U.S. is undercounted.
"The current data on presumptive and lab-confirmed cases and deaths are underestimates," CDC spokesman Scott Pauley told ABC News earlier this month. "Right now, we believe that the number of deaths we have reported paints an informative picture of the scope of epidemic."
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"It's likely that COVID-19 related deaths may not be included on a death certificate or COVID-19 might be a factor related to an individual's death but not the main cause," he said.
Dr. Robert Glatter, assistant professor of emergency medicine and an attending emergency physician at Lenox Hill Hospital in Manhattan, said the crisis hit before certain protocols could be established.
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"There is still no formal uniform platform for reporting coronavirus-related deaths in the US," Glatter said. "Along with a lack of test kits or even rapid antigen identification kits, the reality is that many states have been unable to categorize deaths as COVID vs. non-COVID."
Glatter said that even in February most hospital systems and medical examiners did not yet have access to COVID-19 testing.
He said it is also possible that, before public health officials detected community spread within the US, many people who died of the coronavirus disease were diagnosed simply with influenza-like illnesses or pneumonia.
ABC News contributed to this report.