Autopsy Diagnoses

Autopsy diagnosis represents an interpretation of objective, primarily morphologic, findings. For the next of kin, attending physicians, insurance companies, and public health authorities, these diagnosis sheets are important documents, but they may become meaningless in the future. Interpretations change, names of syndromes and diseases change, and so do autopsy diagnoses. This is one of the reasons why protocols should include objective descriptions.

Autopsy diagnoses can be reported and listed: 1) in a standard sequence (for example, cardiovascular system, respiratory system, digestive system, and so forth) to facilitate anatomic orientation, statistical analysis, and coding; 2) in order of causal relationships and relative importance (for example, chronic alcoholism, alcoholic cirrhosis, ruptured esophageal varices, and gastrointestinal hemorrhage); or 3) in a problem-oriented fashion. The first method is preferred by statisticians and those charged with coding, whereas the latter two methods appeal most to the clinician because more interpretative information is provided. Problem-oriented autopsy diagnoses and protocols (see below) are essential wherever problem-oriented medical records are used (1,2).

PRELIMINARY DIAGNOSIS Forms that we fill out in the autopsy room contain:

• Name, age, weight, length, clinic number, and autopsy number of the patient;

• Names of resident and staff pathologists;

• Preliminary autopsy diagnosis, primarily in the order of causal relationships;

• Directions as to which organs and lesions to photograph, to prepare for organ review, or to save permanently; and

• Directions for histologic sectioning and staining.

Space for the last two items is provided on the back of the preliminary autopsy form.

FINAL AUTOPSY DIAGNOSIS Forms contain the identifying data as listed with the preliminary form, and the actual findings in three main categories: 1) main cause of death; 2) other major diseases and findings; and 3) additional findings. Major surgical procedures or other important diagnostic and therapeutic interventions that may have been carried out are listed as a fourth category. Thus, if a patients died during an attempt to clamp a leaking cerebral artery aneurysm, the diagnosis would state under "Immediate Cause of Death" (see below), "Leaking cerebral artery aneurysm (for attempted surgical repair, see below under "Surgeries")." The actual procedure would then be listed under "Surgeries." Procedures such as surgery or other interventions should not be listed under "Causes of Death" or under "Contributing Conditions" unless that is indeed the intended meaning that the pathologist wants to convey. Copies of the final diagnosis, typically with an explanatory cover letter, are encoded and filed, mailed to the clinicians who cared for the patient, and forwarded to the appropriate quality assurance officers or committees.

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