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The Autopsy Report


The autopsy report is a description and interpretation of the findings at necropsy and provides a record of the completed case as seen from the perspective of the anatomic pathologist. The document is part of the patient's medical record or, in the case of a fetus, the mother's medical record. As such, it is confidential; in accordance with the institution's regulations for medical records, the information is shared with the patient's clinicians, appropriate hospital committees (quality of care, infection control), next of kin, immediate family members acknowledged by the next of kin, or legal appointee. Government agencies may request autopsy reports. Beyond these individuals and institutions, however, the pathologist or medical records representative should release the autopsy only under the authority of the proper writ or court order. The data contained within the report may be processed for general use if kept anonymous.

The main purpose of generating an autopsy report is to record and communicate the postmortem findings in an organized fashion that can be understood by a broad range of readers, from attending physicians to family members. The expectation is that the report will provide definitive answers to medical issues. Thus, the autopsy pathologist must become proficient in diverse fields. Accurate information must be conveyed with clarity, insight, and authority. The autopsy report is the product of intense labor, thoughtful assessment, and purposeful reporting of clinicopathologic information in a concise document. In this era of merged medical record systems with broad user access, it is important to give consideration to what information is released with the autopsy report into the general medical record. Some information would be better maintained only within departmental records, including billing information, specimen tracking, administrative notes, correspondences, and most digital images. This is usually achieved by careful setup of the features of the laboratory information systems software being used to generate the report.

Autopsy reporting is usually performed in two phases, with release of a preliminary (provisional) report shortly after the prosection and a final report when the postmortem analysis is finished. The preliminary report includes an outline listing initial diagnoses that are mostly based on gross findings. The timeline for completion of hospital autopsy reports is dictated by institutional requirements and local regulations, but in the United States these usually follow the accreditation requirements of the College of American Pathologists in which a written preliminary report (including anatomic findings) must be completed within 2 working days, and the final report must be completed within 30 days for routine cases and 90 days for complicated cases. Meanwhile, the Joint Commission for hospital accreditation requires the preliminary report to be completed within 3 days and the final report within 60 days unless exceptions for complicated cases are established by the medical staff. Most institutions make provisions in their reporting system for a later addition to a finalized report, released as an addendum, often reporting results from special studies. For reports that require significant modification of the existing report content, an amendment report should be released, which should be directed conscientiously to individuals closely following the autopsy results. The timeline and manner of forensic autopsy reporting is regulated at the state level in the United States and does not follow the above hospital-based guidelines.

There is considerable variation in the format and length of final autopsy reports, depending on the needs of the institution and its personnel. For example, a teaching hospital that also uses the autopsy for educational purposes and research may require a more detailed report that covers all systems, even normal ones. In contrast, other institutions (community hospitals, medical examiner's offices, military hospitals) may use an abbreviated report focused on the major clinical problem just before death. Thus, each institution must establish a standard for autopsy reports to fit its own needs and to meet the requirements of the accrediting agencies. The final appearance of the report is also determined by practical limitations of the software used to produce the report and archive case information. The Autopsy Committee of the College of American Pathologists has suggested a format including a list of headings for the autopsy report.

The final report should be versatile enough to accommodate the different interests of the individuals expected to use it. For example, the health care delivery team is likely to expect an analysis of the impact of disease and effect of treatment, as well as a cause of death. The patient's physician and social worker may use the autopsy report as a vehicle for communication with family members; interpretation of the anatomic data within the clinical context by the physician is helpful to the family in understanding the disease course. The autopsy report is often perceived as the final word, providing answers to questions that family or friends may have regarding the disease process or the care rendered. In fact, the report can be useful in reassuring a family upset over the management of the patient, and the autopsy report may help with the grieving process. The institution can use the report for both quality assurance and quality improvement. Furthermore, in academic centers, autopsy reports can be used in teaching exercises. The various data contained within the autopsy report can be used for future study by scientists, the institution, or the public health authority. Such diverse uses of the autopsy report demand a consistent approach.

Overview of the Autopsy Report

In complete form, the standard autopsy report consists of six parts:

  • 1.

    Final Anatomic Diagnosis

  • 2.

    Clinical Summary

  • 3.

    Gross Findings

  • 4.

    Microscopic Findings

  • 5.

    Additional Findings

  • 6.

    Clinicopathologic Correlation or Case Discussion

The first section of the report, Final Anatomic Diagnosis (FAD), is a list of anatomic diagnoses—the findings from the postmortem examination in most concise form. The FAD is often placed first in the autopsy report, incorporated with a header containing demographic data, as the autopsy face sheet . This front page position provides an accessible digest of the entire case. Clinical Summary, the second section, consists of a summary of the relevant aspects of the patient's medical record. It provides an overview of historical aspects, physical signs, and laboratory data relevant to the clinical issues, including pathologic diagnoses from surgical specimens. The Gross Findings section provides a description of the anatomic findings at postmortem examination, including radiographs and other imaging studies. It is the only permanent record of the pathologist's observations and measurements of the body cavities and organs. The Microscopic Findings section relates the histologic data primarily; immunohistochemical and electron microscopic findings are also included in this section. The optional Additional Findings section communicates ancillary studies such as microbiologic, toxicologic, molecular, chromosomal, or other laboratory studies performed on material obtained from the postmortem examination. The last section of the report, Clinicopathologic Correlation, is an interpretation of the significant anatomic findings within the clinical setting. A terse interpretive summary is sometimes referred to as a Final Note. Some reports include a discussion of the case within a wider context based on individual or departmental experience or possibly a literature review.

Considering its various uses and the variety of institutions that perform autopsies, the autopsy report has evolved in many different ways. No matter what the format, an autopsy report should at least contain the demographic and clinical information shown in Box 11-1 to function as an independent document. The FAD must be included because it is the barest list of results. One concept of an autopsy report is that of a list of diagnoses with no description; the raw data (including description) are retained by the pathology department for dissemination on request. Another is an outline of diagnoses with extended description only for abnormal organs. These formats have the advantage of a short completion time. Alternatively, there is the complete report in prose, including clinical history, all anatomic data, and the final anatomic diagnoses. Such reports generally have case discussion sections that range from a terse summary of the major clinicopathologic correlations to an extensive discussion of several interesting aspects of the case.

Box 11-1
Minimum Information to be Included in Autopsy Reports

Standard header template containing:

  • Institution name and address

  • Autopsy service contact information

  • Patient name

  • Medical record number

  • Date of birth

  • Age, sex, (indication if a stillborn)

  • Date/time of death

  • Stated clinical history

  • Autopsy case number

  • Date/time of autopsy

  • Prosector

  • Attending pathologist

Anatomic diagnoses from autopsy (often in outline form)

Pictorial representations used alone or in combination with a narrative have been suggested but have not found favor in the general autopsy report. In the future, increased use of digital images as supplements may enhance the presentation of the data and even facilitate shortening of the report, but it should be remembered that the reports are read by a diverse audience including grieving family members, who could find some images disturbing. It is probably best to restrict dissemination of images to those interested (such as providers) who request an image. Protocols designed as extensions to the Problem-Oriented Medical Record System have not been widely accepted. The classic autopsy report is narrative in form, although only experienced pathologists are able to dictate a report without cues. Most pathologists rely on a template or synoptic report. The generalized use of computerized pathology information systems makes generation of the autopsy narrative from a template relatively easy.

In practice, few individuals read the entire autopsy report. Some sections must seem rather irrelevant, even dry, to the nonpathologist. Yet the data must be presented in such a way that they will be accessible in the future to individuals with special interests (e.g., subspecialty consultants, research scientists). The FAD and final note are probably the most commonly read sections. These high-profile sections should be intelligible to a general audience with a medical, but not necessarily pathology, background.

The following provides the basis for the autopsy report that we use in the university hospital. The finished product has the hallmarks of the “academic” style—fairly detailed description, analysis, and clinicopathologic discussion—all of which make the report somewhat lengthy. One of the objectives of the autopsy service in the teaching hospital is pathology resident and fellow training; our approach is to teach the complete autopsy so that trainees will be able to handle varied cases in future practice. Preparation of the autopsy report is instructional in several ways. Formulation organizes the pathologist's view of the case and directs the focus. It also prompts the pathologist to update his or her knowledge of the relevant area of medicine.

Final Anatomic Diagnosis

This first section of the autopsy report provides an overview of the case. The FAD is a union of the gross anatomic diagnoses made at the time of postmortem examination (essentially the provisional anatomic diagnoses) and the histologic diagnoses.

Overall Organization

There are a number of different ways of organizing the individual diagnoses, but each should present the diagnoses in a hierarchy starting with the major pathology that explains the patient's terminal course and ending with incidental findings of lesser consequence to the patient's health.

FAD by Pathogenetic Themes

The first approach is to list anatomic diagnoses related by pathogenetic themes, as shown in the following example:

  • I.

    Consequences of hypovolemic shock following rupture of abdominal aortic aneurysm

    • A.

      Diffuse alveolar damage, lungs

    • B.

      Acute subendocardial myocardial infarct, left ventricle, anteroseptal

    • C.

      Acute tubular injury, kidneys

  • II.

    Hypertensive atherosclerotic cardiovascular disease

    • A.

      Severe atherosclerosis, aorta

    • B.

      Hypertrophy, heart, left ventricle

    • C.

      Benign nephrosclerosis, kidneys

The objective is to provide the basis for a logical overview of each disease process, enabling the pathologist to show a connection between diagnoses or relate them to a procedure. This formulation clearly organizes consequences of disease process; however, some overlap may occur among categories, requiring repetition of diagnoses under different themes. For example, left ventricular cardiac hypertrophy may reflect both systemic hypertension and valvular heart disease.

FAD by Organ Systems

A second approach to organizing the FAD is to list anatomic diagnoses by organ systems, a scheme that does not emphasize pathogenetic relationships. Adding a phrase such as “in association with,” “following,” or “secondary to,” however, can link consequences with pertinent disease processes that may not be obvious, as in the following example:

    • I.

      Diffuse alveolar damage following hypovolemic shock in association with ruptured abdominal aortic aneurysm

      Centriacinar emphysema, lungs

    • II.

      Acute tubular injury, kidneys consistent with shock

      Benign nephrosclerosis associated with history of hypertension

FAD by Organ System With Systemic Integration as Needed

In the Organ System approach, there are three notable exceptions to categorical organ system listings. The first exception encompasses diagnoses that apply to the body as a whole, such as edema, jaundice, sepsis, maceration, nutritional status, malformation complexes, or systemic diseases. The second includes combining diagnoses of the body cavities as a single group. Finally, the third exception involves disseminated disease, for which sites of local extension or metastasis, or both, are grouped under the organ system of the primary process. Those three exceptions are demonstrated in the following example:

  • I.

    Prostatic adenocarcinoma, Gleason grade 7, with extension to right seminal vesicle and bladder wall, as well as metastasis to pelvic and paraaortic lymph nodes, thoracic and lumbar spine, and lungs

    • A.

      Cachexia

    • B.

      Acute cystitis

  • II.

    Acute bronchopneumonia, right lower lobe

  • III.

    Fibrinous adhesions, right pleural cavity

    • Serosanguineous effusions, pleural cavities

    • Fibrous adhesions, pericardial cavity

    • Serous ascites

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