Guidelines for Reports by Autopsy Pathologists / Edition 1

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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. The book 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, the book 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. The book is aimed at pathologists in training, but will also be of benefit to seasoned pathologists who want to improve their reports.

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Editorial Reviews

Doody's Review Service
Reviewer: Katie L Dennis, MD (University of Kansas Medical Center)
Description: This concise manual describes how to write autopsy reports, including how to describe disease and injury, form opinions, and communicate effectively with families and physicians. Instructions on how to properly fill out a death certificate are included as well as sample report formats and opinions.
Purpose: The book provides guidelines for producing well-constructed autopsy reports, including not only how best to form opinions, but also how to communicate those opinions effectively.
Audience: Although pathologists in training, such as residents or fellows, are the intended audience, practicing autopsy pathologists and forensic pathologists also will find this an excellent reference to have on hand.
Features: All aspects of the autopsy report and death certificate are covered, along with explanations of the purpose of each section of the report. Helpful subjects, such as how to describe diseases and injuries, what information to include and omit, common errors to avoid, record retention, and how to determine the cause, manner, and mechanism of death are included. There is even a chapter devoted to writing style, structure, and grammar.
Assessment: This is a very useful book for any pathologist performing autopsies, but especially for pathologists in training who are just learning how to report autopsy findings. Particularly useful are the numerous examples throughout the book and in the appendixes. This is a valuable resource for trainees wanting to learn how to accurately interpret autopsy findings, and how to communicate those findings to the personnel who read the reports.
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Product Details

  • ISBN-13: 9781617379000
  • Publisher: Springer-Verlag New York, LLC
  • Publication date: 11/5/2010
  • Edition description: Softcover reprint of hardcover 1st ed. 2008
  • Edition number: 1
  • Pages: 128
  • Product dimensions: 0.31 (w) x 6.14 (h) x 9.21 (d)

Table of Contents

Preface
•
List of Appendices *

List of Figures. *

Acknowledgments *

Table of Contents *

Part I. Autopsy Prool *

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 *

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