Guidelines for Reports by Autopsy Pathologists (eBook)

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 *
Business Records *
Physical Evidence *