Purpose And Principles Of Preparation

autopsy protocol represents a permanent record of objective, primarily morphologic findings, with little interpretation. Organs and lesions are described by: 1) location and relationship to other organs and structures, 2) size, 3) weight, 4) shape, 5) color, 6) consistency, 7) odor, and 8) other special features such as texture of cut surfaces. Thus, the protocol describes the characteristics, extent, and severity of a lesion or condition interpreted in the diagnosis.

Numerous forms with the correct case identification must be filled out for each autopsy, such as diagnosis sheets, protocol forms, weight sheets, and requests for histologic, microbiologic, or chemical studies. Computerized forms with the same identifying data on each sheet have made this task much easier.

There is no ideal format for protocols because the requirements that have to be satisfied are to some extent mutually exclusive. Autopsy protocols should contain complete, detailed, yet concise and well-organized descriptions of abnormal findings. To describe a normal appearing organ as "normal," without any further specifications, appears acceptable in principle but often puts too much trust in the experience of the pathologist. Narrative parts of the protocol must be entered in the computer, proofread, and signed. Autopsy protocols should require little time to complete by pathologists and secretaries. Protocol forms should be self-explanatory so that the resident pathologist is in some way guided by the protocol. And, finally, protocol forms should be inexpensive.

Each institution has to compromise. Experience of personnel may be limited and manpower may be in short supply, while the need persists for optimal protocols for service, training, research, and record-keeping. Autopsy protocol writing is an art. Descriptions should be brief yet complete. There should be no interpretations and no descriptions of the mechanics of dissection ("The left atrium of the heart is opened, and the mitral valve is found to be..."). The statement that a nodule is yellow will not become more informative by adding, "in color."

Sizes should be stated in centimeters, and comparisons with fruits or other objects should be avoided. Weights should be stated in grams and kilograms, and volumes in liters and milliliters.

For autopsy protocols in medicolegal cases, Chapter 2 should be consulted.

NARRATIVE PROTOCOLS This time-honored type of protocol is inexpensive and may be most instructive. Virchow's protocols (11) are classic examples.

The narrative protocol permits detailed description of complicated findings and, at the same time, utmost brevity in describing the normal. There are no space limitations, and yet no space is wasted by printed provisions for abnormalities that do not apply. Unfortunately, good narrative protocols can be expected only from experienced pathologists whose style is lucid and whose descriptions are fitting. An established narrative pattern must be maintained. Those not fluent in the language in which the protocol is written may have additional difficulties with this type of protocol.

PROTOCOLS BASED ON SENTENCE COMPLETION AND MULTIPLE CHOICE SELECTION The protocols can be completed with ease and speed. Even the inexperienced can be expected to provide the most important information in most instances. These protocols can be tailored to specific types of autopsies, such as sudden infant death cases (12). In paper forms, space limitations often make addenda on separate sheets necessary, and at the same time much paper is wasted by printed provisions for abnormalities that do not apply. In computer-based forms, many of these disadvantages can be avoided. Computers can generate programmed text (13) when key descriptive phrases or words are spoken but whether this will be useful in practice remains to be seen.

PICTORIAL PROTOCOLS Hand-drawings, photographs, or computer-generated outlines of organs may be part of any protocol but protocols in which pictures are the main form of documentation have not stood the test of time.

Fig. 17-1. The vital statistics registration system in the United States. Adapted with permission from ref. (7).

Responsible person or agency

Birth certificate

Death certificate

Fetal death certificate (stillbirth)

Physician, other professional attendant, or hospital authority

1. Completes entire certificate in consultation with parent(s); physician's signature required

2. Files certificate with local office of district in which birth occurred

1. Completes medical certification and signs certificate

2. Returns certificate to funeral director

1. Completes or reviews medical items on certificate

2. Certifies to the cause of fetal death and signs certificate

3. Returns certificate to funeral director

4. In absence of funeral director, files certificate

Funeral director

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