The Autopsy Report

Updated: May 30, 2012
  • Author: Mark A Koponen, MD, MT(ASCP); Chief Editor: Kim A Collins, MD, FCAP  more...
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Overview

Overview

The reasons for performing hospital autopsy examinations are varied, ranging from simple to complex. To the family, the reason may simply be to find out the cause of the death. To the physicians, the reason may be to uncover the progression and interactions of multiple disease processes and the effects of therapy. Ultimately, the autopsy examination provides a clinicopathologic correlation to be used by both the family and the patient's physicians.

The hospital autopsy pathologist is confronted with a wide variety of unique cases requiring specialized problem solving and autopsy procedures. These autopsy findings are correlated with the medical history (some of which is known before the autopsy and some becomes known after the examination), premortem imaging studies, premortem and postmortem laboratory studies, microscopic findings of tissues, toxicology, and other associated medical procedures and documents. Thus, often the real labor involved in a modern autopsy examination begins and ends outside of the morgue.

The autopsy examination culminates in the generation of an autopsy report. This report may be relatively simple and straightforward or may be voluminous and exceedingly complex. Ultimately, the autopsy report is not only a written description of the autopsy findings but also assembles and correlates these findings with the clinical setting, laboratory results, and imaging studies. Thus, the autopsy report is the product of the postmortem anatomic examination and a complete assessment and integration of the patient's clinical data brought together to provide a purposeful accounting of this information. The value of the autopsy, no matter how thorough and skillfully performed, is greatly diminished if the findings and correlations cannot be adequately communicated to end users of this information. (Autopsy communications will be discussed in a separate article.)

Various formats exist for autopsy reports. Reports may be exceedingly lengthy and detailed, as in a teaching institution, to an abbreviated and focused report, as is sometimes seen in community hospitals and medical examiners' offices. Several national medical organizations (National Association of Medical Examiners, College of American Pathologists) and textbooks on autopsy pathology have recommended specific guidelines for organizing and reporting the autopsy findings. [1, 2, 3, 4, 5]

A relatively standardized approach to assembling autopsy reports is seen largely as facilitating the review of reports by third parties and to facilitate data retrieval and analysis. In addition, such recommendations are seen as a move to standardization of policies and procedures, particularly in medical examiner offices. Although these recommendations vary slightly, the general format provides for a series of standardized headings to logically report autopsy findings. The use of "checklist" autopsy reports is discouraged.

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Suggested Autopsy Report Headings

The various autopsy report headings provide some degree of flexibility. Sections may be combined or placed in a different order to facilitate the flow of information and to accommodate various individual or institutional styles. It is most important that the autopsy report contain all the information necessary to "stand alone" to support the cause of death statement.

Suggested headings for autopsy reports are as follows [2] :

  • Autopsy Face Sheet
  • Historical Summary
  • Examination Type, Date, Time, Place, Assistants, Attendees
  • Presentation, Clothing, Personal Effects, Associated Items
  • Evidence of Medical Intervention
  • Postmortem Changes
  • Postmortem Imaging Studies
  • Identification
  • Evidence of Injury
  • External Examination
  • Internal Examination
  • Histology Cassette Listing
  • Microscopic Descriptions
  • Toxicology Results, Laboratory Results, Ancillary Procedure Results
  • Pathologic Diagnoses
  • Summary and Comments
  • Cause of Death Statement
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An Overview of the Autopsy Report

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

This portion of the report 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

The 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 places 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.

Also, it is prudent to leave certain medical appliances in place 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 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 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 is for listing any postmortem imaging performed and the results of such studies.

Features of identification

Identification is rarely 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.

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 exam 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] (The fetal, perinatal, and pediatric autopsy will be discussed in a separate article.)

Internal examination

The internal portion of the examination is the central portion of the examination 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, 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 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 method that is utilized 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.

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CONCLUSION

Autopsy reports are medicolegal documents that not only report the anatomic findings of the postmortem examination but which also provide detailed clinicopathologic correlations. Anything less greatly diminishes the value and utility of the autopsy examination. The performance of an autopsy has barely changed in the past 100 years, but it is precisely this clinicopathologic correlation -- and the questions that only an autopsy can answer -- which ensures the procedure its place in the practice of medicine.

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