Guidelines for Reports by Autopsy Pathologists

Guidelines for Reports by Autopsy Pathologists is intended to help the autopsy pathologist produce reports that communicate well. Having evolved from a coll- tion of faculty critiques of the autopsy reports, summary and opinion reports, scene reports, and death certi?cates produced by residents in anatomic pathology and f- lows in forensic pathology, the book emphasizes topics that have been troublesome for trainees. For clinicians, the medical record describes their work product. For autopsy pathologists, the written report is the work product and demands an acco- ingly higher standard of composition. Most reports produced by pathologists can be divided into objective and subjective elements, or, in other words, ?ndings and opinions. The pathologist must have a clear understanding of the linkage between the two. When composing a report, the autopsy pathologist should serve the goal of c- municating to the parties who will read the report, namely, the case pathologist him- or herself (at a later date), attorneys, the family of the decedent, and other physicians. I believe that careless and imprecise thinking leads to sloppy language, and that sloppy language leads to careless and imprecise thinking. In my experience, pathologists who learn how to clearly express and organize their ?ndings and op- ions in a written format make more detailed and focused observations at the autopsy table.

Preface *

List of Appendices *

List of Figures. *

Acknowledgments *

Table of Contents *

Part I. Autopsy Protocol *

Purpose, Structure, and Organization *

Purpose *

Structure *

Organization. *

Measurements *

Diagnostic Terms *

External Examination *

Inventory of Parts *

Clothing and Surface Evidence *

Identifying Features *

Signs of Death *

Organization of External Findings *

Therapy *

Organ and Tissue Donation *

Wounds by Type *

General Organization *

Outside-in *

Paragraphs *

Impact Wounds *

Blade Wounds *

Hanging *

Firearm Wounds *

Burns and Fire Deaths *

Wounds by Organ *

Measurements *

Bones: General *

Skull and Dura *

Ribs *

Long Bones and Pelvis *

Vertebrae *

Ligaments, Joints and Muscle *

Body Cavities *

Great Vessels *

Heart *

Central Nervous System *

Lungs *

Liver *

Spleen *

Internal Examination *

Autopsy Procedures *

Wounds, Therapy, and Donations *

Body Cavities *

Heart and Great Vessels *

Lungs *

Liver, Bile Ducts, Gallbladder and Pancreas *

Reticuloendothelial System *

Genitourinary System *

Endocrine Organs *

Digestive Organs *

Musculoskeletal System *

Neck *

Head *

Tumors *

Part II. Opinion Reports *

The Logic of Opinion Formation *

Definitions of Cause, Mechanism, and Manner *

Global Approach *

Synthesis of Cause, Mechanism, and Manner *

Competing Diseases and Injuries *

Degree of Certainty *

Diagnoses in Tabular Format *

Purpose *

Structure *

Diagnosis or Finding? *

What to Include *

Cause of Death as Diagnosis *

Completeness and Etiologic Specificity *

Diagnoses in Narrative Format: The Summary and Opinion Report *

Purpose *

Structure *

History *

Autopsy Findings *

Opinions *

Part III. Other Reports *

Ancillary Laboratory Reports *

Integration and Signature *

Fixed Organs *

Microscopic Descriptions *

Scene Investigation by Pathologist *

Purpose *

Structure *

Case identification *

Background Information. *

Environment *

Body *

Actions Taken *

Animal Bones *

Purpose *

Structure *

Content *

Part IV. Style *

Construction *

Sentences *

Paragraphs *

Abbreviations *

Parentheses *

Adjectives *

Verbs *

Natural Indexing *

Dictating to Avoid Editing *

Attorneys’ Rules of Construction *

Inserting Minor Opinions *

Word Order *

Terminology *

Anatomical Terminology *

Latin and Greek *

Slang *

Brand Names *

General Terminology *

Part V. Death Certification *

Purpose and History *

Death certificate forms. *

Establishing that death occurred *

Cause of death *

Codeable Causes of Death *

Format for Cause of Death Opinion *

Degree of Certainty *

Approximate Interval: Onset to Death *

Manner of death *

Purpose *

Manner of Death Problems *

Life Insurance Issues Related to Manner of Death *

Circumstances *

How Injury Occurred *

Location of Injury *

Place of Injury *

Part VI. Record Retention *

Purpose *

Types of Records *

Autopsy Reports *

Case File Notes *

Death Certificates *

Deposition Transcripts *

Police Reports *

Hospital Patient Records *

Autopsy Recordings *

Investigations of Bodies to be Cremated *

No-jurisdiction Case Notes *

Business Records *

Physical Evidence *