The Autopsy Report: Overview, Suggested Autopsy Report Headings, An Overview of the Autopsy Report (2024)

More detailed discussion of suggested standard headings [2] for the autopsy are reviewed in this section.

Autopsy face sheet

The autopsy face sheet or the final anatomic diagnosis (FAD) is the first portion of the report that lists the autopsy diagnoses as well as all of the pertinent patient demographic data. This portion of the report is highly variable and institutionally dependent, but it should contain the autopsy results in an outline form. The College of American Pathologists has developed a recommended autopsy face sheet, which can easily be modified for use in any setting. [5]

Historical summary

The historical summary is used to place the autopsy in context with perhaps a listing of the goals of the examination. A statement of the patient's medical history, laboratory and imaging studies, and historical circumstances may be included to give the reader of the report a sense of perspective of the events leading to the individual's death and postmortem examination.

Examination type, date, time, place, assistants, and attendees

This section reports the nature of the examination (complete autopsy, partial autopsy) and under what authority the examination is performed. The date, time, and place of the examination provides the when and where of the performance of the examination. This listing of time and place may give insight to the availability of ancillary studies or other limitations to the examination, which may prove important at a later date. The listing of attendees and assistants provides a manner in which to document the witnesses to the autopsy.

Presentation, clothing, personal effects, and associated items

Documentation of how the body was received and the state of the remains before the examination is highly important. The clothing, jewelry, and personal effects are to be painstakingly documented (and perhaps photographed). These items may have evidentiary value or at least very important emotional value to families, who always require an exacting accounting of such items. In addition, the state of the body upon receipt may help explain findings and artifacts not related to the autopsy examination and which occurred before receipt of the remains. Again, photographic documentation of the body as it was received may prove invaluable in addressing questions posed at a later date.

Evidence of medical intervention

This portion of the report is for a listing of all medical devices, no matter how routine, that were placed in the course of medical therapy. All tubes, catheters, puncture sites, bandages, and other appliances that were placed in the patient are important and help to place iatrogenic artifacts into context. An example is soft-tissue hemorrhage associated with catheter placement within the neck. Without the description of the catheter in this section and yet the description of soft-tissue hemorrhage in the internal portion of the examination raises questions about the origin of the hemorrhage and may bring into question the completeness and accuracy of the autopsy report.

It is also prudent to leave certain medical appliances in situ to check their proper placement during the internal portion of the autopsy examination. Endotracheal tubes, nasogastric tubes, and central vascular catheters may not be properly placed, and these findings may be highly important in the final formulation of the cause of death.

Postmortem changes

Documentation of routine postmortem changes aids in interpretation of other autopsy findings. Rigor mortis, livor mortis, skin slippage, discoloration, malodor, etc, aid in establishing or confirming the postmortem interval as well as aid in the interpretation of autopsy findings. Postmortem changes often complicate autopsy findings, in particular the microscopic examination of organs and tissues obtained at the postmortem examination.

Postmortem imaging studies

This section of the report is for listing any postmortem imaging performed and the results of such studies.

Features of identification

Identification of an individual is seldom questioned in a hospital autopsy. Rarely, questions arise and usually occur long after the body is left the morgue. A listing of identifying marks and scars (including detailed descriptions of tattoos and healed surgical incisions), body weight and length, hair color, condition of dentition, etc, are features that are commonly recorded.

Evidence of injury

All external and or internal injuries found on examination, and their number, precise location, size, shape, depth, appearance, etc, are thoroughly detailed in this section of the report. When internal injuries are correlated with external evidence of injury, these findings are also recorded.

External examination

The external portion of the examination, like all other sections of the report, requires detailed observations organized in a logical manner. This portion of the evaluation is especially important in a forensic examination; however, it can also be highly relevant in a hospital autopsy.

The condition of the body externally is often a major concern of the funeral home personnel and, ultimately, the families. Depending on the nature of the case, pertinent negatives can be included throughout the report. Descriptions to include body height, weight, nutrition, body symmetry, eyes (iridies, sclera, conjunctiva), nose, ears, mouth, teeth, neck, chest, abdomen, genitalia, and extremities give the reader of the report a sense of the condition of the body at the time of the examination, and the quality of the detail gives credence to the overall accuracy and thoroughness of the report.

Fetal and perinatal autopsies should include a detailed gross and microscopic examination of the placenta. In addition, pediatric autopsies require additional measurements to be taken (ie, head circumference, abdominal circumference, etc), which should be tabulated in the report. This information places the autopsy findings within a developmental context. [5]

Internal examination

The internal portion of the examination is the central portion of the evaluation and deserves a thoroughness and attention to detail that justifies the autopsy and the original goals of the examination. Obviously, all internal organs should be inspected, weighed, and described. All positive findings should have qualifiers (measurements, color, or degree [eg, mild, moderate, severe]) to give the reader a sense of the magnitude of the abnormality. Pertinent negatives should also be listed based on the peculiarities of the case. A possible outline for the internal examination section of the report follows.

Body cavities

  • Organ arrangement

  • Presence or absence of fluids and adhesions

  • General appearance of viscera (degree of decomposition, color, malodor)

  • Adipose layer of anterior abdominal body wall

Central nervous system

  • Weight

  • Configuration

  • Meninges

  • Abnormalities evident externally (hemorrhage, herniations, infection, etc)

  • Blood vessels

  • Internal abnormalities

  • Ventricular system

  • Pituitary

  • Scalp and skull

Neck

  • General appearance

  • Thyroid gland

  • Lymph nodes

  • Airway

  • Blood vessels

Cardiovascular system

  • Weight

  • Configuration

  • Coronary arteries

  • Valves (including circumferences, if abnormal)

  • Myocardium (including left and right ventricular wall thickness)

  • Aorta and vena cava

Respiratory system

  • Lung weights

  • General appearance

  • Tracheobronchial tree

  • Parenchyma appearance, with details of diffuse or focal lesions

Liver and biliary system

  • Weight

  • Color

  • Consistency

  • Gall bladder and contents

Gastrointestinal tract

  • Esophagus

  • Stomach

  • Pancreas

  • Small intestine

  • Large intestine

  • Rectum

Genitourinary tract

  • Kidney weights

  • Kidney appearance

  • Ureters

  • Bladder

  • Male pelvic organs

  • Female pelvic organs

Reticuloendothelial system

  • Spleen weight

  • Appearance of lymph nodes

  • Thymus (if present)

Musculoskeletal system

  • General appearance of bones, musculature, and soft tissues

Histology cassette listing and microscopic descriptions

Any number of tissues may be submitted for examination, which is dictated by the nature of the case. In addition, at the discretion of the autopsy pathologists, tissues may be retained and preserved in formalin to serve as a source of additional tissue for microscopic examination. Tissues may also be retained and fixed in formalin, resulting in a firmer consistency, which aids in the ability to obtain quality sections.

Toxicology, laboratory, and ancillary procedure results

The results for all tests (including toxicology, microbiology, chemistry, etc) should be listed in a logical sequence. Occasionally, such testing provides important information that is highly important to the final formulation of the cause of death. Listing these results in the autopsy report allow the report to "stand alone," without the addition of pages of supporting documents that can be lost or difficult to place into context.

Pathologic diagnosis

In this section, the final anatomic diagnoses are listed in an organized and systematic manner. This can be done in one of several manners, but in general, the diagnoses should be listed in a hierarchical manner, starting with the most relevant pathologic processes that culminated in the patient's death, and then those of lesser importance and, finally, those of incidental consequence.

One organizational scheme lists the diagnoses by major pathologic entities, followed by subheadings that list the related pathologies or consequences of the major pathologic entity. An example would be the following:

I. Pericardial tamponade.

A. Rupture of acute myocardial infarction of the anterior left ventricular myocardium.

B. Atherosclerotic coronary vascular disease.

C. Thrombosis of the left anterior descending coronary artery.

This manner of listing the autopsy diagnoses connects multiple consequences of the major pathologic entity and provides a series of cause-and-effect relationships for the reader of the report. A drawback of this method is that there may be some redundancy in the listing of diagnoses, as some interrelationship exists between closely related pathologic entities. An example of this would be hypertensive heart disease and atherosclerotic coronary vascular disease, both of which may result in myocardial ischemia and arteriolonephrosclerosis.

A second utilized method lists all diagnoses by organ system, either in a prescribed order or by importance in the overall context of the death. However, this approach does not readily link associated disease processes, particularly processes that involve more than one organ system, such as sepsis or lupus erythematosus. Thus, the various causes and effects can end up linked by long connecting phrases, such as "due to" or "as a consequence of," which may be satisfactory but awkward.

A third approach is to list the cause of death, followed by a list of the "Intervening Cause(s) of Death," a listing of "Other Significant Contributing Conditions to the Death," and finally "Miscellaneous Findings."

Pediatric autopsy reports are often best written in the context of development. Wherever organ weights are listed, normal ranges for the gestational age are also given. Body heights and weights are listed along with the "Percentile for Age."

Summary and comment

This section of the autopsy report is for summarizing the gross and microscopic autopsy findings, along with history and pertinent imaging and laboratory test results. This summary relates the clinical findings with the autopsy findings in a concise fashion and attempts to answers the major questions that were hopefully well defined at the beginning of the examination.

Cause of death statement

The cause of death statement, which is also included on the face sheet, correlates the autopsy report to the cause of death in a standard format.

The summary and comment, along with the cause of death statement, are often combined in a section often called "Opinion." In this section, the cause of death statement is the first or last sentence, with the remainder of the paragraph(s) supporting or leading up to the cause of death.

The Autopsy Report: Overview, Suggested Autopsy Report Headings, An Overview of the Autopsy Report (2024)

FAQs

What information is included in the heading of an autopsy report? ›

Examination Type, Date, Time, Place, Assistants, Attendees

This section makes it clear whether the autopsy was “complete” or otherwise, and under what legal authority the autopsy was performed.

What is an autopsy quizlet? ›

An autopsy is a medical examination of a dead body to determine the cause of death.

What are the 4 steps of an autopsy? ›

An autopsy is a detailed and careful medical examination of a person's body and its organs after death, to help establish the cause of death.
  • Interactive Autopsy Introduction. ...
  • Step 1 - External Examination. ...
  • Step 2 - Internal Examination. ...
  • Step 3 - Viewing the internal organs. ...
  • Step 4 - Removal of the organs.

What is the summary of an autopsy? ›

An autopsy, or post mortem, is the medical examination of a body and the internal organs after a person has died.

What does a full autopsy include? ›

Complete autopsy is defined to include a detailed external examination of the entire body, and an internal examination to include the removal and dissection of all thoraco-abdominal and neck organs, opening the head with the removal and examination of the brain. 2.1.

What information is included in the heading of the document? ›

The correct MLA heading is found on the first page of your paper. It includes your name, instructor, course, and date. MLA format also has a running header with the page number and your last name. It is right-aligned and found on each page.

What is autopsy answer? ›

AutoSys is an automated job control system for scheduling, monitoring, and reporting. These jobs can reside on any AutoSys-configured machine that is attached to a network.

What are the parts of an autopsy? ›

First, a visual exam of the entire body is done, including the organs and internal structures. Then, microscopic, chemical, and microbiological exams may be made of the organs, fluids, and tissues. All organs removed for examination are weighed, and a section is preserved for processing into microscopic slides.

What is the purpose of an autopsy is to determine the _____ of death? ›

An autopsy (also known as a postmortem examination or necropsy) is the examination of the body of a dead person and is performed primarily to determine the cause of death, to identify or characterize the extent of disease states that the person may have had, or to determine whether a particular medical or surgical ...

Can a coroner refuse to do an autopsy? ›

In some situations, despite a written request, the coroner may still refuse to perform an autopsy. In such cases, the family has only one remaining option – arranging a private autopsy. A private autopsy is performed by a private forensic pathologist who is not affiliated with any coroner's office.

Can autopsy be wrong? ›

Indeed, the quality of forensic autopsy activity is always questioned in courts of law; incorrect assessments are dangerous because they can jeopardize the validity of a criminal investigation and thus affect the outcome so that a real culprit may be acquitted or an innocent person convicted.

What do autopsy reports look like? ›

An autopsy report includes details of all the observations, examinations and tests of the body. It typically states the cause of death and the general manner of death. Based on scientific and medical evidence, the pathologist lists the manner of death as one of five categories: Accident.

Who pays for an autopsy when someone dies? ›

If somebody dies under suspicious circumstances, a state or county may call for a forensic autopsy. Taxpayers foot the bill in those situations. In cases where the government sees no need to mandate an autopsy, the family of the deceased can request one — but they may have to pay for it out of pocket.

Can autopsy determine time of death? ›

It is always a best guess. But when the principles are properly applied, the medical examiner can often estimate the physiologic time of death with some degree of accuracy. The most important and most commonly used of these are body temperature, rigor mortis, and lividity.

What are the five manners of death? ›

The classifications are natural, accident, suicide, homicide, undetermined, and pending. Only medical examiner's and coroners may use all of the manners of death. Other certifiers must use natural or refer the death to the medical examiner.

What is included in a preliminary autopsy report? ›

The preliminary report provides an initial indication of significant findings at autopsy. It is important to note that this preliminary report is based on the macroscopic findings alone and the diagnoses may be modified in the final autopsy report on the basis of the information from all autopsy investigations.

What information from an autopsy report would be important to estimate the time of death? ›

But when the principles are properly applied, the medical examiner can often estimate the physiologic time of death with some degree of accuracy. The most important and most commonly used of these are body temperature, rigor mortis, and lividity.

What does a full post-mortem report contain? ›

In most cases, a pathology report will start with general information, such as the person's medical history and the circumstances of their death. This is usually followed by a description of the outside of the body and the internal organs.

What information can often be obtained from an autopsy? ›

A: An autopsy is performed to determine the cause of death and the extent and nature of injuries or natural disease processes that caused death.

References

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