Nearly half of all resident physicians in New York City say that they’ve knowingly reported a wrong cause of death for a patient, according to a new report.

The report, which appears in Preventing Chronic Disease, shows that most — 76.8 percent — of those who admitted reporting a wrong cause of death did so because “the system would not accept the correct cause,” while 40.5 percent said that they did it because an office personnel “instructed them to ‘put something else.'” Meanwhile, 30.7 percent said they did it because the medical examiner told them to.

The report included survey responses from 521 residents who were participating in 38 residency programs; about a third of the residents were considered high-volume respondents. Researchers found that the most inaccurately over-reported cause of death was heart disease, while causes of death including septic shock and acute respiratory distress syndrome may actually be underreported.

They also found that just a third of resident doctors in New York City say that they think that causes of death are reported accurately, with resident doctors completing 11 or more death certificates over a three year period being more likely to say the reporting system is inaccurate than those completing 10 or fewer death certificates.

“Residents need better training in proper completion of death certificates, including cause-of-death identification, when and why causes should be amended, and the implications of cause-of-death data for their community,” researchers, from St. Luke’s–Roosevelt Hospital Center and Columbia University College of Physicians and Surgeons, wrote in the report. “Historically, residents have not been well educated as to what they can and cannot put on death certificates, and most have not undergone formal training in death certificate completion.”