Guidelines for Reports by Autopsy Pathologists / Edition 1

Guidelines for Reports by Autopsy Pathologists / Edition 1

by Vernard Irvine Adams
     
 

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ISBN-10: 1603274723

ISBN-13: 9781603274722

Pub. Date: 07/25/2008

Publisher: Springer-Verlag New York, LLC

Traditionally, pathology residents have learned how to write autopsy reports by trial-and-error, with oral feedback from local mentors. Now, pathologists and pathologists in training throughout the English-speaking world have access to a manual that describes what should be in an autopsy report, how to organize the material, and what the purposes are. Guidelines

Overview

Traditionally, pathology residents have learned how to write autopsy reports by trial-and-error, with oral feedback from local mentors. Now, pathologists and pathologists in training throughout the English-speaking world have access to a manual that describes what should be in an autopsy report, how to organize the material, and what the purposes are. Guidelines for Reports by Autopsy Pathologists lists numerous bad habits to avoid, and offers examples of effective report construction. It covers not only how to describe diseases and injuries, but also how to formulate and write opinions. As a supplement, Guidelines for Reports by Autopsy Pathologists also contains recommendations on record retention schedules for medical examiners (not everything needs to be saved in perpetuity), and how to formulate opinions for death certificates. Aimed at pathologists in training, Guidelines for Reports by Autopsy Pathologists will alos benefit the seasoned pathologists who want to improve their reports. Written for: Pathologists; physicians who perform autopsies; resident pathologists, hospital pathologists, and forensic pathologists; medical examiners

Product Details

ISBN-13:
9781603274722
Publisher:
Springer-Verlag New York, LLC
Publication date:
07/25/2008
Edition description:
2008
Pages:
128
Product dimensions:
6.30(w) x 9.30(h) x 0.60(d)

Table of Contents


Autopsy Protocol     1
Purpose, Structure, and Organization     1
Purpose     1
Structure     1
Organization     3
Measurements     3
Diagnostic Terms     3
External Examination     4
Inventory of Parts     4
Clothing and Surface Evidence     6
Identifying Features     7
Signs of Death     10
Organization of External Findings     12
Therapy     12
Organ and Tissue Donation     13
Wounds by Type     14
General Organization     14
Outside-In     15
Paragraphs     15
Impact Wounds     16
Blade Wounds     17
Hanging     19
Firearm Wounds     20
Burns and Fire Deaths     23
Wounds by Organ     24
Measurements     24
Bones: General     25
Skull and Dura     25
Ribs     26
Long Bones and Pelvis     26
Vertebrae     27
Ligaments, Joints, and Muscle     27
Body Cavities     28
GreatVessels     28
Heart     29
Central Nervous System     29
Lungs     30
Liver     30
Spleen     30
Internal Examination     30
Autopsy Procedures     31
Wounds, Therapy, and Donations     31
Body Cavities     31
Heart and Great Vessels     33
Lungs     35
Liver, Bile Ducts, Gallbladder, and Pancreas     36
Reticuloendothelial System     37
Genitourinary System     37
Endocrine Organs     37
Digestive Organs     38
Musculoskeletal System     39
Neck     39
Head     39
Tumors     40
Opinion Reports     41
The Logic of Opinion Formation     41
Definitions of Cause, Mechanism, and Manner     41
Global Approach     43
Synthesis of Cause, Mechanism, and Manner     44
Competing Diseases and Injuries     44
Degree of Certainty     46
Diagnoses in a Tabular Format     46
Purpose     47
Structure     47
Diagnosis or Finding?      48
What to Include     48
Cause of Death as Diagnosis     49
Completeness and Etiologic Specificity     49
Diagnoses in a Narrative Format     50
Purpose     50
Structure     51
History     52
Autopsy Findings     53
Opinions     54
Other Reports     57
Ancillary Laboratory Reports     57
Integration and Signature     57
Fixed Organs     58
Microscopic Descriptions     58
Scene Investigation by Pathologist     59
Purpose     59
Structure     59
Case Identification     60
Background Information     60
Environment     60
Body     61
Actions Taken     61
Animal Bones     61
Purpose     61
Structure     61
Content     62
Style     63
Construction     63
Sentences     63
Paragraphs     63
Abbreviations     63
Parentheses     64
Adjectives     64
Verbs     65
Natural Indexing     66
Dictating to Avoid Editing     67
Attorneys' Rules of Construction     67
Inserting Minor Opinions     68
Word Order     68
Terminology     69
Anatomical Terminology     69
Latin and Greek     70
Slang     70
Brand Names     71
General Terminology     71
Death Certification     79
Purpose and History     79
Death Certificate Forms     80
Establishing That Death Occurred     80
Cause of Death     83
Codeable Causes of Death     83
Format for Cause-of-Death Opinion     86
Degree of Certainty     88
Approximate Interval: Onset to Death     88
Manner of Death     89
Purpose     89
Manner-of-Death Problems     90
Life Insurance Issues Related to Manner of Death     93
Circumstances     93
How Injury Occurred     93
Location of Injury     95
Place of Injury     95
Record Retention     97
Purpose     97
Types of Records     98
Autopsy Reports     98
Case File Notes     98
Death Certificates     98
Deposition Transcripts     99
Police Reports     99
Hospital Patient Records     99
Autopsy Recordings     99
Investigations of Bodies to Be Cremated     100
No-Jurisdiction Case Notes     100
Business Records     100
Physical Evidence     100
Index     125

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