Autopsy reports have changed little in over 100 years. They are a crucial part of medical transcription. They provide the so-called clinicopathological correlation between anatomical evidence and supporting proof as to the cause of death should it not be readily evident. An autopsy must contain information that proves the cause of death beyond a shadow of a doubt to be considered “valid.”
Tools of the trade for transcription ofautopsy.
Headings are very important when transcribing autopsy reports. You might see these: Autopsy Facesheet 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
This is usually present on all autopsy reports and contains valuable information. It is also sometimes called the FAD—or final anatomical diagnoses. It is most often in an outline form and notes the summary of the findings/diagnoses. It also gives demographical information regarding the person the autopsy is performed on. The American College of Pathologists has developed a recommended facesheet format that can be modified to suit the needs of any institution. Autopsy is also called a postmortem exam or necropsy. It is considered a medical procedure and consists of a very thorough examination of the body in order to determine cause and manner of death. It also is used to evaluate for any additional disease and/or injuries that may or may not be present. It goes so far as to note scars and tattoos present on the body as well as condition of all internal organs. In addition to the above, lab studies and/or x-rays may be performed on the body to help delineate cause of death, injuries present or absent, and underlying medical conditions present at the time of death.
This portion of the report details what occurred prior to the patient’s death and can include assumptions as to how the person died (for instance self-inflicted gunshot wound or homicide by strangulation) This information may be supplanted by facts surrounding the death such as how the patient was found, accidental trauma such as a fall, etc. As much information as possible is gathered about the circumstances surrounding the patient’s death to confirm or disprove injuries, toxicology studies, physical findings, etc. and incorporated into a summary at the beginning of the report in order for the reader to identify a probable cause of death. This is usually a preliminary educated guess as to the cause of death but will be confirmed or disproved in the final summary after postmortem examination.
This section of the autopsy report details when it took place (date, time), where it took place (for instance what state and county), if any assistants were present or anyone else attended the autopsy. Again, an autopsy is considered a medical procedure and consists of any number of measurements, dissection, collection of specimens, microscopic analysis, x-ray, etc. The autopsy can be complete or partial dependent upon the nature of the person’s death or by whose authority the autopsy is requested. Attendees to an autopsy are considered witnesses to the procedure. Noting the circumstances under which the autopsy was performed provides information indirectly on what studies or services were available at the time of performance of the exam. For instance, if the autopsy was done in a small town where no ancillary services were available, it could conceivably be missing vital information such as toxicology screens or x-rays to check for fractures.
The state of the body at the time of presentation is a critical piece of information. For instance, if the body was discovered in a remote location and was partially decomposed. The state of the body and how it was received are important factors to note in any autopsy. For instance, if a patient died in the ICU and had been resuscitated, it would be important to note that the patient came to the autopsy with evidence of intubation (tubing) and/or IV lines. If the autopsy is being done on a trauma victim, accidental or nonaccidental, any weapons and/or items found at the scene of the crime will also be included in the autopsy history details and probably photographed as evidence.
In order to delineate whether a death was the result of malpractice for example, a vital part of the autopsy report involves listing all devices present on the body at the time of death. This could include but is not limited to bandages, tubing of any sort, catheters such as Foley catheters, devices or appliances—such as a cardiac pacemaker. Any of these items could have direct or indirect bearing on the person’s demise so must be documented. Changes evident on the body must be noted that have any association with medical equipment such as an infiltrated IV line—hemorrhage into the skin surrounding a puncture site for the line as an example.
General changes such as livor mortis, rigor mortis, odors, discoloration, even elasticity of the skin help to determine the cause of death. These changes are documented to help interpret cause of death. They can also aid in the determination of the time of death and may or may not in the final analysis determine the cause of death accurately. However, these findings usually add additional information to the query, “What caused this patient to die?”
In some cases, imaging such as MDCT (multidirectional CT scan) or MRI may be used to determine if an autopsy is necessary. Imaging can be used to evaluate areas where dissection might be difficult or unnecessary if imaging can determine a probable cause of death. X-rays like dental x-rays can be used to determine the identity of a body which may have been recovered without proof of who they are. An example would be a person presumably homeless, found down with no driver’s license or proof of identity on the body. Imaging is used to identify bullet fragments, injury patterns, foreign bodies or fracture fragments. All of this information is applied to the overall picture in determining cause of death and/or antecedent trauma prior to death.
For the most part, hospital autopsies do not require identification of the patient as most have been entered into the hospital system. All scars and identifying marks including details of tattoos are noted for documentation of the body’s identity. Super important to note are surgical scars as this speaks to the person’s medical history and procedures that he or she may have had performed within their lifetime. Height, weight, hair color, state of dentition, etc. are all additional facts to be documented in the autopsy report.
Forensic autopsies rely more heavily on external examinations than hospital autopsies—but notation on a hospital autopsy of severe edema of the legs would be a critical notation. External condition of the body has a direct bearing on funeral arrangements. In postmortem exam of a fetus, detailed gross and microscopic information about the placenta is given. Fetal or pediatric autopsies document items such as head or abdominal circumference, weight, etc that might be factors in determining cause of death.
This category is generally broken up into several sections and is full of significant detail. Body cavities Organ arrangement – are they in proper position/missing? Is there presence or absence of fluids and adhesions internally? Visceral general appearance (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
Reticuloendothelial system Spleenweight Appearance of lymph nodes Thymus (if present) Musculoskeletal system General appearance of bones, musculature, and soft tissues
These may or may not be used asheadings and/or subheadings.
SUMMARY OF INJURIES This section of the autopsy report details internal injuries. It may be correlated with evidence of any injuries noted on the external examination.HISTOLOGY CASSETTE LISTING AND MICROSCOPIC DESCRIPTIONS (BLOCK LISTING AND HISTOLOGIC DESCRIPTION per CAP) Tissues of many different kinds or singular sets of tissue may be retained for further examination as determined by the type of autopsy case. This section usually also includes a cataloguing of each slide for reference.
TOXICOLOGY, LABORATORY AND ANCILLARY PROCEDURE RESULTS This section lists tests such as chemistries, toxicology, microbiology etc run on specimens postmortem. Information can be gathered things like blood glucose or alcohol levels, whether drugs were present in the person’s system at the time of death and what kind, etc. Photos could be added to the report as well (documenting an abscess found during internal examination). There would also be supporting lab cultures listed in the report to confirm what type of bacteria caused the abscess.
This section of the autopsy report lists and organizes all anatomic diagnoses present causing and contributing to a person’s demise. Information is usually listed in the most important first manner though in a critically ill patient, many factors could ultimately be responsible for death. Another organizational method defines diagnoses by major pathologic entities, followed by subheadings that list related pathologies or byproducts of the major pathologic item.
Example of sample heading and subcategories of diagnosesFINAL DIAGNOSES:I. Pulmonary failure. A. Multiple pulmonary thromboemboli. 1. Left upper lobe main pulmonary artery with 85% occlusion. 2. Right upper lobe infarct of the anterior segment 3 x 4 x 2 cm. 3. Acute pneumonitis of bilateral lower lungs with diffuse bronchial congestion. B. Pulmonary congestive changes and edema (each lung weighing 600 g). C. Changes of moderate pulmonary hypertension with plaquing and scarring. D. No evidence of cocci in either lung.
The autopsy report in this section summarizes and reviews the overall autopsy findings correlated with historical information, imaging studies and/or lab results which back up the diagnoses (preliminary and final). This section most often is used to provide answers to the question why or how did someone die in more simple terms.
This part of the autopsy report includes the findings mentioned on the facesheet and then relates the findings found on autopsy to delineate the cause of death. It may also be called the OPINION part of the report and renders an educated opinion based upon physical and clinical findings as to why the person died.
This is a heading that is used to add additional information should it become available at a later time. It is always dated information and does infer that cases are always “open” should additional information become available later that may be added to the original findings.
These additional headings are sometimesused in the External Examination portionof an Autopsy. (Sometimes used assubheadings)
These would be used as subheadings under External Examination General – discoloration, odor, hydration, body habitus, hair distribution Head – scalp, oral cavity, nasal cavity, forehead, ears, etc. Neck – masses, scars, abrasions or contusions, markings, etc. Torso – breasts, genitalia, inguinal regions, buttocks, anterior and posterior torso, etc. Upper Extremities – elbows, wrists, forearms, hands, etc. Lower Extremities – thighs, knees, legs, ankles, feet, etc. Evidence of Injury – external evidence of any injury (or presence of no injury) Summary – lists the pertinent external findings
These subheadings can be used to organize the autopsy report in terms of the internal examination. Torso – describes pelvic, abdominal, thoracic organs and tissues Head – describes brain, dura, scalp, skull, etc. Neck and Pharynx – describes tongue, pharynx, neck vessels, etc. Spinal Column and Cord – description of spinal column and cord if necessitated Additional Dissection – description of specific areas such as a certain muscle or placenta
Instead of subheadings noted above, these subheadings are used under the 2nd level heading for torso, organized in paragraph form, subheading placed as beginning wording for the paragraph. Evisceration/Dissection Method – how organs were removed—en masse, piecemeal or en bloc (Letulle, Virchow or Rokitansky method) Chest and Abdomen Walls and Cavities – statements about ribs, soft tissues, peritoneal cavity, etc. Organ Weights – sometimes a table is used to note organ weights Cardiovascular System – description of heart and vessels, etc. Respiratory System – descriptions of pulmonary lobes, diaphragms, etc. Digestive System – descriptions of stomach to anus Hepatobiliary System – descriptions of liver, gallbladder, etc. Reticuloendothelial System – describes lymph nodes, spleen, bone marrow, etc. Urogenital Systems – describes kidneys, bladder, reproductive organs, etc. Endocrine Organs – describes thyroid, adrenals, parathyroid glands, etc
Typical listing style:FINAL DIAGNOSES:I. GUNSHOT WOUND OF CHEST WITH: A. PERFORATIONS OF RIGHT RIB 7, RIGHT LUNG, PERICARDIAL SAC, AND SUPERIOR VENA CAVA. B. HEMOTHORAX (APPROXIMATELY 1000 mL). C. HEMOPERICARDIUM (APPROXIMATELY 250 mL).II. GUNSHOT WOUND OF RIGHT SHOULDER WITH: A. PERFORATIONS OF RIGHT RIB 1, STRAP MUSCLES, THYROID GLAND, AND TRACHEA. B. ASPIRATION OF BLOOD.III. GUNSHOT WOUND OF HEAD WITH PERFORATION OF SKULL.IV. GRAZE WOUNDS OF RIGHT SHOULDER AND LEFT FOREARM.
Followed by more information such as Cause of Death, Manner of Death, where it was performed, who attended, etc. CAUSE OF DEATH: GUNSHOT WOUNDS OF TORSO WITH PERFORATIONS OF SUPERIOR VENA CAVA AND TRACHEA WITH ASPIRATION OF BLOOD. MANNER OF DEATH: HOMICIDE (SHOT BY OTHER PERSON(S)). I hereby certify that I, Xxxxxx Xxxxx, M.D., City Medical Examiner I, have performed an autopsy on the body of Xxxxx X. Xxxxxx on the 11th day of July, 1998, commencing at 9:00 a.m. in the XXXXXX Mortuary of the Office of Chief Medical Examiner of the City of Xxx Xxxx. This autopsy was performed in the presence of Dr. Xxxxxxx and Dr. Xxxxxx.
Documentation of the External Examination:EXTERNAL EXAMINATION: The body is of a well- nourished, well-developed, average-framed, 5 feet 8-1/2 inch, 164 pound, medium brown-skinned black man, whose appearance is consistent with the reported age of 18 years. The tightly curled black scalp hair is 1/2 inch. There is a 1/8 inch moustache and 1/2 inch goatee…
POSTMORTEM CHANGES: Rigor mortis is easilybroken and symmetrical. Livor mortis is notapparent. The body is cold. There are severalclusters of larvae on the face and torso.INJURIES: There are several gunshot wounds ofthe head and torso. These injuries are labeled"A" through "F" for descriptive purposes only; nosequence is implied. The directions are statedwith reference to the standard anatomicalplanes with the body measured in the horizontalposition.
The list of injuries would be listed as below with paragraph following each describing:A. Perforating Gunshot Wound of Right Chest: There is a…B. Penetrating Gunshot Wound of Right Shoulder: There is a….C. Graze Wound of Right Shoulder: There is a…D. Abrasions: There are…
The Internal Examination might be done in this type of stacked format:INTERNAL EXAMINATION: NECK: The cervical vertebrae and hyoid bone are without fracture. The upper airway is not obstructed. The base of the tongue is unremarkable. BODY CAVITIES: The thoracic and abdominal organs are in the normal anatomic relations. There are no fibrous adhesions of the pericardial sac, pleural, or peritoneal cavities.
Remember that autopsies are done for several reasons such as murder, determination of death suddenly due to unknown cause, trauma, intrauterine death of a fetus, suicide, etc.Even with different formats the basic information is the same and answers questions like: Why did the person die? What ultimately caused death? How long has the person been dead? Did the person have other contributing medical illnesses, injuries or extenuating circumstances?
The role of the MT in autopsy transcription is to accurately document the findings Present the report according to the formatting requirements of each client Ensure documentation in noting all medical terms, English terms, laboratory values, anatomical or physiology phrase or words Possess excellent healthcare documentation skills to ensure accuracy Ensure reasonable turnaround time for dictation completion
Click HERE to download PDF files such as an Autopsy Glossary and an Autopsy Words and Phrases file Click HERE to watch another PowerPoint presentation on facts about autopsy Click HERE to read my article on hubpages.com about Transcribing Autopsy ReportsPowerPoint presentations are also available in PDF format for download.