PREPARATION OF
AUTOPSY DOCUMENTS.
DRAFT COPY ONLY.
(Procedure 203).
http://www.netautopsy.org/axsop/axsop203.htm


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United States Government Work, uncopyrighted, public-domain, DRAFT COPY ONLY. This document does not necessarily represent the views or policies of any United States Government agency. This document is provided "as is", without warranty of any kind, express or implied, including but not limited to the warranties of merchantability, fitness for a particular purpose and non-infringement. In no event shall the authors be liable for any claim, damages or other liability, whether in an action of contract, tort or otherwise, arising from, out of, or in connection with the document or the use or other dealings made with the document.

PRINCIPLE OF THE TEST.


Valid medicolegal documents are necessary, in order for the autopsy to proceed.

SPECIMEN REQUIRED.


At the Veterans Affairs Medical Health Care System (VAMHCS), autopsies are performed on deceased patients with a valid Authorization for Autopsy (U. S. Standard Form 523), a complete hospital chart, and a death note signed by a physician included in the chart.

REAGENTS, INSTRUMENTATION.


Valid medicolegal documents.

STEP-BY-STEP DESCRIPTION.


1. The three documents required for autopsy, namely AUTHORIZATION FOR AUTOPSY, COMPLETE HOSPITAL CHART, AND DEATH NOTE, should be obtained by the Medical Administration Service (MAS) within a single shift (i.e., 8 hours), or on the morning of the next day after the patient's death, and is delivered by MAS personnel to the attention of the autopsy assistant in the autopsy suite.

2. At the time the documents are complete, MAS should issue a MailMan (electronic mail) message to the Administrative Officer, Laboratory Service, the Chief, Autopsy Section, and the on-call attending pathologist. The email should be addressed as PRIORITY MAIL to mailgroup G.AUTOPSY.

3. The Authorization for Autopsy (U. S. Standard Form 523) should be obtained from the patient's next-of-kin or guardian, in the following order of priority: (a) spouse; (b) adult child; (c) parent; (d) adult sibling; (e) adult grandchild; (f) adult nephew or niece; (g) grandparent; (h) uncle or aunt. THE CHIEF OF STAFF MAY SIGN AN AUTHORIZATION ONLY IF THERE IS NO LEGAL NEXT-OF-KIN, AND IF THE REMAINS ARE UNCLAIMED. In place of U. S. Standard Form 523, there may be a transcribed telephone consent given by the next of kin and prepared by the Medical Administration Service.

4. If the spouse does not sign the authorization, then the DECEDENT AFFAIRS CLERK in MAS will include a VistA® entry, with the autopsy alert, containing an explanation, such as, 'spouse deceased' or 'patient never married'. Likewise, a written explanation should be provided for each person in the above priority list who does not sign the authorization, such as, 'patient has no children', 'parents deceased', etc. If authorization cannot be obtained from next-of-kin or guardian, then this fact should be determined by MAS within 48 hours of the patient's death, and authorization will be obtained from the Chief of Staff. If there is a longer delay for authorization, then MAS should include a signed, written explanation on the authorization form. The hospital chart must be complete, in order for the pathologist to determine the clinical events leading up to death, special procedures taken at autopsy (e.g., infectious disease), and the clinicopathologic questions to be addressed at autopsy. The death note, usually included as part of the hospital chart, must contain the date and time of the patient's death, and must be signed by a physician.

REFERENCE.


1. Hutchins GM, ed.
Autopsy Performance and Reporting.
Northfield, IL: College of American Pathologists. 1990.