Guidelines for Reports by Autopsy Pathologists

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 *Busines