GUIDELINES FOR REPORTS BY AUTOPSY PATHOLOGISTS

About this book

Traditionally, pathology residents have learned how to write autopsy reports by trial-and-error, with oral feedback from local mentors. Now, pathologists and pathologists in training throughout the English-speaking world have access to a manual that describes what should be in an autopsy report, how to organize the material, and what the purposes are. Guidelines for Reports by Autopsy Pathologists lists numerous bad habits to avoid, and offers examples of effective report construction. It covers not only how to describe diseases and injuries, but also how to formulate and write opinions. As a supplement, Guidelines for Reports by Autopsy Pathologists also contains recommendations on record retention schedules for medical examiners (not everything needs to be saved in perpetuity), and how to formulate opinions for death certificates. Aimed at pathologists in training, Guidelines for Reports by Autopsy Pathologists will alos benefit the seasoned pathologists who want to improve their reports.

Written for:

• Pathologists; physicians who perform autopsies; resident pathologists, hospital pathologists, and forensic pathologists; medical examiners

Keywords:

• Autopsy opinions
• Autopsy reporting
• Autopsy reports
• Body cavity exam
• External body exam
• Internal organ exam
• Lab reports
• Wound examination

Table of contents

• 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