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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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Guidelines for Reports by Autopsy Pathologists Guidelines for Reports by Autopsy Pathologists Vernard Irvine Adams, MD Author Chief Medical Examiner, Hillsborough County, Florida and Department of Pathology and Cell Biology, University of South Florida, Tampa, Florida, USA Author Vernard Irvine Adams Chief Medical Examiner Hillsborough County Department of Pathology and Cell Biology University of South Florida Tampa, FL 33617 USA ISBN: 978-1-60327-472-2 e-ISBN: 978-1-60327-473-9 Library of Congress Control Number: 2008929467 2008 Humana Press, a part of Springer Science+Business Media, LLC All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Humana Press, 999 Riverview Drive, Suite 208, Totowa, NJ 07512 USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. c Printed on acid-free paper 9 8 7 6 5 4 3 2 1 springer.com Preface Guidelines for Reports by Autopsy Pathologists is intended to help the autopsy pathologist produce reports that communicate well. Having evolved from a collection of faculty critiques of the autopsy reports, summary and opinion reports, scene reports, and death certificates produced by residents in anatomic pathology and fellows in forensic pathology, the book emphasizes topics that have been troublesome for trainees. For clinicians, the medical record describes their work product. For autopsy pathologists, the written report is the work product and demands an accordingly higher standard of composition. Most reports produced by pathologists can be divided into objective and subjective elements, or, in other words, findings and opinions. The pathologist must have a clear understanding of the linkage between the two. When composing a report, the autopsy pathologist should serve the goal of communicating to the parties who will read the report, namely, the case pathologist him- or herself (at a later date), attorneys, the family of the decedent, and other physicians. I believe that careless and imprecise thinking leads to sloppy language, and tha