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 is the overview of autopsy? ›

An autopsy is a detailed systematic external and internal examination of a corpse carried out by a pathologist or one or more medicolegal experts to ascertain the underlying and possible contributing causes of death and, depending on the jurisdiction, the manner of death as well.

What does the autopsy report include? ›

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.

What are the 5 steps of autopsy? ›

  • Step 1 - External Examination. ...
  • Step 2 - Internal Examination. ...
  • Step 3 - Viewing the internal organs. ...
  • Step 4 - Removal of the organs. ...
  • Step 5 - Removing the brain. ...
  • Step 6 - Examining the organs. ...
  • Step 7 - Returning organs to the body. ...
  • Step 8 - Sewing up the body.

What should every autopsy file include? ›

The investigative files should include but not be restricted to the following: all reports, investigator's notes, sketches and death scene photographs, reports of autopsy and laboratory analyses of evidence, copies of all forms completed by the coroner to include chain-of-custody forms and laboratory request forms.

How long does it take for autopsy results? ›

Autopsy reports are usually completed within 60 days from the date of autopsy; however, there are cases which can take 90 days or longer depending on the complexity of the case.

Who pays for an autopsy when someone dies? ›

If the death is an out of hospital death and /or under suspicious circumstances, the Coroner will review the facts and MAY order an autopsy. This expense is paid for by the County. If, however the family is requesting an autopsy state statute states that the party requesting the autopsy is responsible for payment.

Can anyone read an autopsy report? ›

Autopsy reports may not be public if the autopsy is performed as part of a law enforcement investigation. No statute directly addresses access to coroner's reports. Some counties have taken the position that such reports are not public under the medical records exception and investigation exception.

What can be seen in 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.

How do you fill out an autopsy report? ›

How to fill out autopsy report template form. Start by gathering all necessary information about the deceased, including their name, age, date of death, and any known medical history. Begin documenting the external examination of the body, noting any visible injuries, scars, or tattoos. Take photographs if necessary.

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.

What are the 4 things that autopsies can determine? ›

The principal aims of an autopsy are to determine the cause of death, mode of death, manner of death, the state of health of the person before he or she died, and whether any medical diagnosis and treatment before death were appropriate.

Why is the tongue removed during autopsy? ›

Both terms essentially mean "examination after death." Why is the tongue removed during autopsy? The tongue is removed during autopsy to thoroughly examine the oral cavity, access other throat structures, document any abnormalities, take tissue samples for further examination, and eliminate obstruction.

What is included in a complete autopsy? ›

Definitions 2.1. 1. 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.

Are pictures included in an autopsy report? ›

Yes, some reports do include pictures and/or anatomical diagrams. We suggest that if you chose to request a copy of the report that you either ask for these images not to be included or have someone else receive the report on your behalf.

What type of evidence is an autopsy report? ›

The medico-legal autopsy is performed in order to determine whether death was the result of natural disease or violence. The ultimate objective is to ascertain facts which may be used as substantive evidence to prove or disprove circumstances or conditions indicating legal responsibility.

What is an autopsy and why is it important? ›

An autopsy is a detailed dissection of a deceased person, done to determine why they died. If you and your family are dealing with the sudden loss of a loved one, you may find comfort in getting answers at this difficult time. But you should also know that autopsies don't always have to be done.

How is an autopsy performed step by step? ›

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 are the principles and basics of autopsy? ›

Autopsy Procedure. Whether the autopsy is forensic or medical, there is a procedure that the pathologist must follow. There are two parts, the external examination, where information is collected from the outside of the body, and the internal examination, where incisions are made, and the internal organs are examined.

What is the primary objective of the autopsy is to determine? ›

The principal aims of an autopsy are to determine the cause of death, mode of death, manner of death, the state of health of the person before he or she died, and whether any medical diagnosis and treatment before death were appropriate.

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