How to on medical transcription of autopsy reports.

1. Formatting & Other Considerations

2.  Autopsy reports have changed little in over
100 years. They are a crucial part of medical
transcription. They provide the so-called
clinicopathological correlation between
anatomical evidence and supporting proof as
to the cause of death should it not be readily
evident.
 An autopsy must contain information that
proves the cause of death beyond a shadow
of a doubt to be considered “valid.”

3. Tools of the trade for transcription of
autopsy.

4. Headings are very important when transcribing autopsy reports. You might see these:
 Autopsy Facesheet
 Historical Summary
 Examination Type, Date, Time, Place, Assistants, Attendees
 Presentation, Clothing, Personal Effects, Associated Items
 Evidence of Medical Intervention
 Postmortem Changes
 Postmortem Imaging Studies
 Identification
 Evidence of Injury
 External Examination
 Internal Examination
 Histology Cassette Listing
 Microscopic Descriptions
 Toxicology Results, Laboratory Results, Ancillary Procedure Results
 Pathologic Diagnoses
 Summary and Comments
 Cause of Death Statement

5.  This is usually present on all autopsy reports and contains
valuable information. It is also sometimes called the FAD—or
final anatomical diagnoses. It is most often in an outline form
and notes the summary of the findings/diagnoses. It also gives
demographical information regarding the person the autopsy is
performed on. The American College of Pathologists has
developed a recommended facesheet format that can be
modified to suit the needs of any institution.
 Autopsy is also called a postmortem exam or necropsy. It is
considered a medical procedure and consists of a very thorough
examination of the body in order to determine cause and manner
of death. It also is used to evaluate for any additional disease
and/or injuries that may or may not be present. It goes so far as
to note scars and tattoos present on the body as well as condition
of all internal organs. In addition to the above, lab studies
and/or x-rays may be performed on the body to help delineate
cause of death, injuries present or absent, and underlying
medical conditions present at the time of death.

6.  This portion of the report details what occurred prior
to the patient’s death and can include assumptions as
to how the person died (for instance self-inflicted
gunshot wound or homicide by strangulation)
 This information may be supplanted by facts
surrounding the death such as how the patient was
found, accidental trauma such as a fall, etc.
 As much information as possible is gathered about
the circumstances surrounding the patient’s death to
confirm or disprove injuries, toxicology studies,
physical findings, etc. and incorporated into a
summary at the beginning of the report in order for
the reader to identify a probable cause of death.
 This is usually a preliminary educated guess as to the
cause of death but will be confirmed or disproved in
the final summary after postmortem examination.

7.  This section of the autopsy report details when it took place
(date, time), where it took place (for instance what state and
county), if any assistants were present or anyone else attended
the autopsy.
 Again, an autopsy is considered a medical procedure and consists
of any number of measurements, dissection, collection of
specimens, microscopic analysis, x-ray, etc.
 The autopsy can be complete or partial dependent upon the
nature of the person’s death or by whose authority the autopsy is
requested.
 Attendees to an autopsy are considered witnesses to the
procedure. Noting the circumstances under which the autopsy
was performed provides information indirectly on what studies or
services were available at the time of performance of the exam.
For instance, if the autopsy was done in a small town where no
ancillary services were available, it could conceivably be missing
vital information such as toxicology screens or x-rays to check for
fractures.

8.  The state of the body at the time of presentation
is a critical piece of information. For instance, if
the body was discovered in a remote location
and was partially decomposed.
 The state of the body and how it was received
are important factors to note in any autopsy. For
instance, if a patient died in the ICU and had
been resuscitated, it would be important to note
that the patient came to the autopsy with
evidence of intubation (tubing) and/or IV lines.
 If the autopsy is being done on a trauma victim,
accidental or nonaccidental, any weapons and/or
items found at the scene of the crime will also
be included in the autopsy history details and
probably photographed as evidence.

9.  In order to delineate whether a death was the
result of malpractice for example, a vital part of
the autopsy report involves listing all devices
present on the body at the time of death. This
could include but is not limited to bandages,
tubing of any sort, catheters such as Foley
catheters, devices or appliances—such as a
cardiac pacemaker. Any of these items could
have direct or indirect bearing on the person’s
demise so must be documented.
 Changes evident on the body must be noted that
have any association with medical equipment
such as an infiltrated IV line—hemorrhage into
the skin surrounding a puncture site for the line
as an example.

10.  General changes such as livor mortis, rigor
mortis, odors, discoloration, even elasticity
of the skin help to determine the cause of
death. These changes are documented to
help interpret cause of death.
 They can also aid in the determination of the
time of death and may or may not in the
final analysis determine the cause of death
accurately. However, these findings usually
add additional information to the query,
“What caused this patient to die?”

11.  In some cases, imaging such as MDCT (multidirectional CT
scan) or MRI may be used to determine if an autopsy is
necessary. Imaging can be used to evaluate areas where
dissection might be difficult or unnecessary if imaging can
determine a probable cause of death.
 X-rays like dental x-rays can be used to determine the
identity of a body which may have been recovered without
proof of who they are. An example would be a person
presumably homeless, found down with no driver’s license
or proof of identity on the body.
 Imaging is used to identify bullet fragments, injury
patterns, foreign bodies or fracture fragments. All of this
information is applied to the overall picture in determining
cause of death and/or antecedent trauma prior to death.

12.  For the most part, hospital autopsies do not
require identification of the patient as most have
been entered into the hospital system.
 All scars and identifying marks including details
of tattoos are noted for documentation of the
body’s identity.
 Super important to note are surgical scars as this
speaks to the person’s medical history and
procedures that he or she may have had
performed within their lifetime.
 Height, weight, hair color, state of dentition,
etc. are all additional facts to be documented in
the autopsy report.

13.  Forensic autopsies rely more heavily on external
examinations than hospital autopsies—but
notation on a hospital autopsy of severe edema
of the legs would be a critical notation.
 External condition of the body has a direct
bearing on funeral arrangements.
 In postmortem exam of a fetus, detailed gross
and microscopic information about the placenta
is given.
 Fetal or pediatric autopsies document items such
as head or abdominal circumference, weight, etc
that might be factors in determining cause of
death.

14. This category is generally broken up into several
sections and is full of significant detail.
 Body cavities
 Organ arrangement – are they in proper
position/missing?
 Is there presence or absence of fluids and adhesions
internally?
 Visceral general appearance (degree of
decomposition, color, malodor)
 Adipose layer of anterior abdominal body wall

15.  Central nervous system
 Weight
 Configuration
 Meninges
 Abnormalities evident externally (hemorrhage,
herniations, infection, etc)
 Blood vessels
 Internal abnormalities
 Ventricular system
 Pituitary
 Scalp and skull

16.  Neck
 General appearance
 Thyroid gland
 Lymph nodes
 Airway
 Blood vessels

17.  Cardiovascular system
 Weight
 Configuration
 Coronary arteries
 Valves (including circumferences, if abnormal)
 Myocardium (including left and right
ventricular wall thickness)
 Aorta and vena cava

18.  Respiratory system
 Lung weights
 General appearance
 Tracheobronchial tree
 Parenchyma appearance – diffuse or focal
lesions absence or presence

19.  Liver and biliary system
 Weight
 Color
 Consistency
 Gallbladder and contents

20.  Gastrointestinal tract (or system)
 Esophagus
 Stomach
 Pancreas
 Small intestine
 Large intestine
 Rectum

21.  Genitourinary tract (or system)
 Kidney weights
 Kidney appearance
 Ureters
 Bladder
 Male pelvic organs
 Female pelvic organs

22.  Reticuloendothelial system
 Spleenweight
 Appearance of lymph nodes
 Thymus (if present)
 Musculoskeletal system
 General appearance of bones, musculature,
and soft tissues

23. These may or may not be used as
headings and/or subheadings.

24. SUMMARY OF INJURIES
 This section of the autopsy report details
internal injuries. It may be correlated with
evidence of any injuries noted on the external
examination.
HISTOLOGY CASSETTE LISTING AND
MICROSCOPIC DESCRIPTIONS (BLOCK LISTING
AND HISTOLOGIC DESCRIPTION per CAP)
 Tissues of many different kinds or singular sets of
tissue may be retained for further examination
as determined by the type of autopsy case. This
section usually also includes a cataloguing of
each slide for reference.

25. TOXICOLOGY, LABORATORY AND ANCILLARY
PROCEDURE RESULTS
 This section lists tests such as chemistries,
toxicology, microbiology etc run on specimens
postmortem. Information can be gathered things
like blood glucose or alcohol levels, whether
drugs were present in the person’s system at the
time of death and what kind, etc.
 Photos could be added to the report as well
(documenting an abscess found during internal
examination). There would also be supporting
lab cultures listed in the report to confirm what
type of bacteria caused the abscess.

26.  This section of the autopsy report lists and
organizes all anatomic diagnoses present
causing and contributing to a person’s
demise. Information is usually listed in the
most important first manner though in a
critically ill patient, many factors could
ultimately be responsible for death.
 Another organizational method defines
diagnoses by major pathologic entities,
followed by subheadings that list related
pathologies or byproducts of the major
pathologic item.

27. Example of sample heading and subcategories of diagnoses
FINAL DIAGNOSES:
I. Pulmonary failure.
 A. Multiple pulmonary thromboemboli.
1. Left upper lobe main pulmonary artery with 85%
occlusion.
2. Right upper lobe infarct of the anterior segment 3 x
4 x 2 cm.
3. Acute pneumonitis of bilateral lower lungs with
diffuse bronchial congestion.
 B. Pulmonary congestive changes and edema (each lung
weighing 600 g).
 C. Changes of moderate pulmonary hypertension with
plaquing and scarring.
 D. No evidence of cocci in either lung.

28.  The autopsy report in this section
summarizes and reviews the overall autopsy
findings correlated with historical
information, imaging studies and/or lab
results which back up the diagnoses
(preliminary and final).
 This section most often is used to provide
answers to the question why or how did
someone die in more simple terms.

29.  This part of the autopsy report includes the
findings mentioned on the facesheet and
then relates the findings found on autopsy to
delineate the cause of death.
 It may also be called the OPINION part of the
report and renders an educated opinion
based upon physical and clinical findings as
to why the person died.

30.  This is a heading that is used to add
additional information should it become
available at a later time.
 It is always dated information and does infer
that cases are always “open” should
additional information become available
later that may be added to the original
findings.

31. These additional headings are sometimes
used in the External Examination portion
of an Autopsy. (Sometimes used as
subheadings)

32. These would be used as subheadings under External Examination
 General – discoloration, odor, hydration, body habitus, hair distribution
 Head – scalp, oral cavity, nasal cavity, forehead, ears, etc.
 Neck – masses, scars, abrasions or contusions, markings, etc.
 Torso – breasts, genitalia, inguinal regions, buttocks, anterior and posterior torso,
etc.
 Upper Extremities – elbows, wrists, forearms, hands, etc.
 Lower Extremities – thighs, knees, legs, ankles, feet, etc.
 Evidence of Injury – external evidence of any injury (or presence of no injury)
 Summary – lists the pertinent external findings

33. These subheadings can be used to organize the autopsy
report in terms of the internal examination.
 Torso – describes pelvic, abdominal, thoracic organs
and tissues
 Head – describes brain, dura, scalp, skull, etc.
 Neck and Pharynx – describes tongue, pharynx, neck
vessels, etc.
 Spinal Column and Cord – description of spinal
column and cord if necessitated
 Additional Dissection – description of specific areas
such as a certain muscle or placenta

34. Instead of subheadings noted above, these subheadings are used under the
2nd level heading for torso, organized in paragraph form, subheading
placed as beginning wording for the paragraph.
 Evisceration/Dissection Method – how organs were removed—en masse,
piecemeal or en bloc (Letulle, Virchow or Rokitansky method)
 Chest and Abdomen Walls and Cavities – statements about ribs, soft
tissues, peritoneal cavity, etc.
 Organ Weights – sometimes a table is used to note organ weights
 Cardiovascular System – description of heart and vessels, etc.
 Respiratory System – descriptions of pulmonary lobes, diaphragms, etc.
 Digestive System – descriptions of stomach to anus
 Hepatobiliary System – descriptions of liver, gallbladder, etc.
 Reticuloendothelial System – describes lymph nodes, spleen, bone
marrow, etc.
 Urogenital Systems – describes kidneys, bladder, reproductive organs,
etc.
 Endocrine Organs – describes thyroid, adrenals, parathyroid glands, etc

35. Typical listing style:
FINAL DIAGNOSES:
I. GUNSHOT WOUND OF CHEST WITH:
 A. PERFORATIONS OF RIGHT RIB 7, RIGHT LUNG,
PERICARDIAL SAC, AND SUPERIOR VENA CAVA.
 B. HEMOTHORAX (APPROXIMATELY 1000 mL).
 C. HEMOPERICARDIUM (APPROXIMATELY 250 mL).
II. GUNSHOT WOUND OF RIGHT SHOULDER WITH:
 A. PERFORATIONS OF RIGHT RIB 1, STRAP MUSCLES,
THYROID GLAND, AND TRACHEA.
 B. ASPIRATION OF BLOOD.
III. GUNSHOT WOUND OF HEAD WITH PERFORATION OF
SKULL.
IV. GRAZE WOUNDS OF RIGHT SHOULDER AND LEFT FOREARM.

36. Followed by more information such as Cause of Death, Manner of
Death, where it was performed, who attended, etc.
 CAUSE OF DEATH: GUNSHOT WOUNDS OF TORSO WITH
PERFORATIONS OF SUPERIOR VENA CAVA AND TRACHEA WITH
ASPIRATION OF BLOOD.
 MANNER OF DEATH: HOMICIDE (SHOT BY OTHER PERSON(S)).
 I hereby certify that I, Xxxxxx Xxxxx, M.D., City Medical Examiner
I, have performed an autopsy on the body of Xxxxx X. Xxxxxx on
the 11th day of July, 1998, commencing at 9:00 a.m. in the
XXXXXX Mortuary of the Office of Chief Medical Examiner of the
City of Xxx Xxxx.
 This autopsy was performed in the presence of Dr. Xxxxxxx and
Dr. Xxxxxx.

37. Documentation of the External Examination:
EXTERNAL EXAMINATION: The body is of a well-
nourished, well-developed, average-framed,
5 feet 8-1/2 inch, 164 pound, medium
brown-skinned black man, whose appearance
is consistent with the reported age of 18
years. The tightly curled black scalp hair is
1/2 inch. There is a 1/8 inch moustache and
1/2 inch goatee…

38. POSTMORTEM CHANGES: Rigor mortis is easily
broken and symmetrical. Livor mortis is not
apparent. The body is cold. There are several
clusters of larvae on the face and torso.
INJURIES: There are several gunshot wounds of
the head and torso. These injuries are labeled
"A" through "F" for descriptive purposes only; no
sequence is implied. The directions are stated
with reference to the standard anatomical
planes with the body measured in the horizontal
position.

39. The list of injuries would be listed as below with
paragraph following each describing:
A. Perforating Gunshot Wound of Right Chest:
There is a…
B. Penetrating Gunshot Wound of Right Shoulder:
There is a….
C. Graze Wound of Right Shoulder:
There is a…
D. Abrasions:
There are…

40. The Internal Examination might be done in this
type of stacked format:
INTERNAL EXAMINATION:
 NECK: The cervical vertebrae and hyoid bone are
without fracture. The upper airway is not
obstructed. The base of the tongue is
unremarkable.
 BODY CAVITIES: The thoracic and abdominal
organs are in the normal anatomic relations.
There are no fibrous adhesions of the pericardial
sac, pleural, or peritoneal cavities.

41. Transcription of Autopsy Reports

42. Remember that autopsies are done for several
reasons such as murder, determination of death
suddenly due to unknown cause, trauma,
intrauterine death of a fetus, suicide, etc.
Even with different formats the basic information
is the same and answers questions like:
 Why did the person die?
 What ultimately caused death?
 How long has the person been dead?
 Did the person have other contributing medical
illnesses, injuries or extenuating circumstances?

43.  The role of the MT in autopsy transcription is
to accurately document the findings
 Present the report according to the
formatting requirements of each client
 Ensure documentation in noting all medical
terms, English terms, laboratory values,
anatomical or physiology phrase or words
 Possess excellent healthcare documentation
skills to ensure accuracy
 Ensure reasonable turnaround time for
dictation completion

44.  Click HERE to download PDF files such as an
Autopsy Glossary and an Autopsy Words and
Phrases file
 Click HERE to watch another PowerPoint
presentation on facts about autopsy
 Click HERE to read my article on hubpages.com
about Transcribing Autopsy Reports
PowerPoint presentations are also available in PDF
format for download.

45. Audrey Kirchner, CMT
360TRAINING.COM
4.22.2013