Practice guidelines for autopsy pathology: autopsy reporting. Autopsy Committee of the College of American Pathologists.

PRACTICE GUIDELINES FOR AUTOPSY PATHOLOGY:
AUTOPSY REPORTING.
AUTOPSY COMMITTEE OF THE
COLLEGE OF AMERICAN PATHOLOGISTS.

Hutchins GM, Berman JJ, Moore GW, Hanzlick R,
Autopsy Committee of the College of American Pathologists.
http://www.netautopsy.org/pracguid.htm

Send comments and correspondence to: George.Moore4@med.va.gov
See also: http://www.medparse.com/gwmcv.htm ............. http://www.medparse.com/protoiad.htm ............. http://www.medparse.com/apdmchap.htm ............. http://www.medparse.com/uniqmddm.htm .............

United States Government Work, uncopyrighted, public-domain. 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 noninfringement. 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. Published as:

Hutchins GM, Berman JJ, Moore GW, Hanzlick R.
Practice guidelines for autopsy pathology: autopsy reporting. Autopsy Committee of the College of American Pathologists.
Arch Pathol Lab Med. 1999 Nov;123(11):1085-1092.
Full Text of Article:
http://www.netautopsy.org/pracguid.htm

ABSTRACT.

The Autopsy Committee of the College of American Pathologists has prepared this revised guideline to reflect changes that have occurred in the reporting or autopsies since the original guideline was published in February, 1995. It is intended to be an instrument to assist pathologists in the reporting of autopsies. The guideline is to be regarded as being primarily an educational tool. Application of these recommendations on autopsy reporting are to be made on the basis of the judgment of the pathologist engaged in a specific case.

INTRODUCTION.

The Autopsy Committee of the College of American Pathologists (CAP) has the responsibility to develop, assess, and revise practice guidelines for autopsy pathology within the framework established by the American Medical Association [1]. The first practice guideline developed by the Autopsy Committee concerned autopsy performance, and addressed the definition of autopsy pathology, the development and review of practice guidelines for autopsy pathology, indications for performing autopsies, autopsy permission, funeral considerations, and some aspects of quality assurance and quality control [2].
The CAP mandates a review of guidelines at three year intervals, and this first guideline has been reviewed by the Autopsy Committee and deemed not to need revision. The Autopsy Committee's second guideline was on autopsy reporting, and this was approved by the CAP House of Delegates on April 13, 1994, the CAP board of governors adopted it as official CAP policy on May 20, 1994, and it was published in February, 1995 [3]. Other guidelines produced by the Autopsy Committee were on autopsy procedures for brain, spinal cord, and neuromuscular system [4], and the perinatal and pediatric autopsy [5]. The Autopsy Committee determined that revision of the guideline on autopsy reporting would be appropriate, and this report is an updated version of the prior publication [3].

As a general principle, autopsy findings should be recorded in a form that will make them useful to the parties who read autopsy reports, or who abstract information from autopsy reports. This includes pathologists, clinicians, family members, lawyers, risk management officers, researchers, epidemiologists, statisticians, and outcome analysts. The pathologist should be aware of the increasing effort to archive autopsy reports in an electronic format. Now and in the future, there will be initiatives to extract data contained within autopsy reports for inclusion into databases. Although the format of the autopsy protocols will vary among institutions, the inclusion of common components will permit a wider use of autopsy data. Every autopsy should include the autopsy facesheet (demographics and list of anatomic diagnoses), a clinical summary, an objective description of the gross autopsy observations, a slide catalogue, reports of ancillary studies, and a clinicopathologic interpretive summary.

The written report complements, but cannot substitute wholly, for cooperation and open lines of verbal communication between pathologists, clinicians, and all other interested parties.

THE AUTOPSY FACESHEET.

The autopsy facesheet, or Final Anatomical Diagnoses, is important for presentation of essential diagnoses, and for computerized indexing and retrieval of the core information in an autopsy report. The suggested format for reporting the demographic and autopsy information on a facesheet is shown in Figure 1, and described below.

Demographic Data. Include the name and address of the institution on the autopsy report, since autopsy reports are frequently distributed outside the institution. Identify the patient by name, hospital number, and possibly social security number, for verification of identity. Verify identifying markers carefully, since if any of them is wrong, it is extremely difficult to locate the correct hospital record.

Assign a unique autopsy case number, in order to have control over institutional record-keeping.

Provide the patient's date of birth and date of death. In the case of neonatal death, the dates should include the months, day, and hours as appropriate. Gestational age may be given for neonatal cases. Stillborns should be designated as such. The birthdate can be a useful cross check for correct patient identification.

If race/ethnicity is listed, it may be indicated according to the following guidelines suggested by the United States Public Health Service (PHS Form 398). The category that most closely reflects the individual's concept of his or her own race/ethnicity should be used in cases of mixed ethnicity. In other words, a person's own declaration of race/ethnicity in their medical record should be regarded as definitive.

I - American Indian or Alaskan Native
A - Asian or Pacific Islander
B - Black, not of Hispanic origin
H - Hispanic
W - White, not of Hispanic origin
U - Undetermined
Definitions of race/ethnicity are described by the U.S. Public Health Service, as follows [6]:

I American Indian or Alaskan Native - A person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal affiliation or community recognition.

A Asian or Pacific Islander - A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands, and Samoa.

B Black, Not of Hispanic Origin - A person having origins in any of the black racial groups of Africa.

H Hispanic - A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.

W White, Not of Hispanic Origin - A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

Indicate gender as follows:

M - male

F - female

U - undetermined

The final admission date, obtained from hospital records, allows calculation of the duration of hospital stay. The date and time of death may be needed for correlation with state records, identification cross checks, death certificate matching, and epidemiologic studies covering fixed ranges of time. State the place of death, ward, hospital service, or other source of the autopsy case, as appropriate. The date and time of autopsy establish the postmortem interval and provide quality assurance for timely performance of autopsies.

Forensic cases should be so designated. State the extent of autopsy, including restrictions. An unrestricted autopsy should be described as such. Permissions and restrictions given by the responsible party should be quoted.

The prosector's name should be included. The prosector is defined as the person who dissects the organs. This may be the same person as the attending pathologist, in which case the name should be listed redundantly.
It is appropriate to include other information on the autopsy facesheet. The patient's address, including the zip code, as well as the patient's usual occupation can often be obtained from admission records, and are useful for epidemiologic studies. A listing of ancillary studies (e.g., microbiology, toxicology, serology, photomicrography, electron microscopy), and the patient's physicians of record should be included on the report. The uses made of the autopsy information, such as conference presentations, report distribution, and persons participating in departmental presentations of the autopsy, may be useful to append to the autopsy document.
Listing of Diagnoses. There are several methods of ordering the diagnoses on the autopsy facesheet that give narrative character to the document and enhance readability.
One method is to divide the diagnoses into two parts, clinical and anatomic. The first part is a list in telegraphic form and temporal sequence of all important clinical states, processes, diagnoses, and treatments. Separation of this component of the report from the pathologic diagnoses provides a useful brief clinical summary, a record of previous surgical or cytology specimens, and a list of important clinical information. The second part lists anatomic diagnoses by importance, by pathogenetic relations, or by organ systems. If this approach is used, clinical information should be clearly delineated as such, and separated from anatomic diagnoses.
Another approach lists diagnoses in pathogenetic sequence, admixing relevant clinical information (listed as "history of" - H/O) as appropriate. It is important that some system be used. A random listing of anatomical diagnosis statements frustrates the reader's ability to make sense of a case from the autopsy facesheet. The inclusion of clinical information greatly enhances the value of the report.

FIGURE 1. AUTOPSY FACE SHEET.

Institution Name and Address
(Preliminary) Anatomical Diagnosis
Patient's Name Hosp/Med Records No. Social Security No.*
Autopsy No.
Age (as appropriate) Gestational Age Birthdate Race/Ethnicity Gender
/ / ____Yrs ____Mos ____Days ___ Hrs _____ Weeks Mo/Day/Year
Final Admission Death Date & Time Place of Death/Ward/Service
Autopsy Date & Time / / / / / / Mo/Day/Year Mo/Day/Year Military Mo/Day/Year Military
Forensic Case Extent of Autopsy Permit: _______________ Prosector(s)
Yes ___ No ___ Embalmed: Yes ___ No ___
Patient's Usual Occupation(s)* Patient's Zipcode* Autopsy Completed
/ / Mo/Day/Year ______________________
Pathologist
Pending Studies**
In Attendance at the Autopsy**
Conference Presentations** Patient's Physicians**
Report Distribution**
List Diagnoses - use continuation pages
*Optional but desirable information
** Inclusion of these items in the face sheet may be useful but should be decided by the individual institution

COMPLETING CAUSE OF DEATH STATEMENTS
OR THE DEATH CERTIFICATE

The words entered into the cause of death section of the death certificate are used in developing epidemiologic information important for public health planning. Although pathologists may not necessarily be directly involved in filling out this information, it may be useful to the patient's physicians if an attempt is made to identify those autopsy findings that will assist in filling out the death certificate with accurate and meaningful cause of death statements[7,8]. Cause of death statements include: 1) the single most important disease/injury that initiated events causing death ("underlying cause of death"); the most important complications/disorders that followed the underlying cause of death and preceded death ("immediate and intermediate cause(s)"); and other significant conditions (diseases/injuries), that contributed to death but did not result in the underlying cause of death. ®MDBU¯®MDNM¯The pathologist is encouraged to include a "cause of death" section or cause of death statement on the autopsy facesheet structured in the same fashion as that present on the death certificate in use in that jurisdiction. This addition to the facesheet may support efforts to derive vital statistics from autopsy databases [9]. If the attending physician has completed the death certificate without knowledge of autopsy findings, the autopsy report may address whether the autopsy findings are consistent with the cause of death as stated on the death certificate. Alternatively, a cause of death statement can be offered in the autopsy report with a suggestion that the death certificate be amended. Preferably, the death certificate should be completed after a cause of death can be determined at autopsy. Bear in mind that most states require that the death certificate be filed within a few days of death, and that most states allow a certificate to be filed as "pending" for completion at a later date, if necessary.
Definitions. The underlying or primary cause of death is defined as the disease or injury that initiated the morbid events leading directly to death, or the circumstances or violence that produced a fatal injury. This underlying cause must always be as etiologically specific as possible and antecedent to all other causes with respect to time and pathologic relationship. Without the underlying cause, death would not have occurred.
The immediate cause of death is defined as the disease, injury, or complication that directly precedes death. Thus, the immediate cause is the ultimate consequence of the underlying cause. The interval between onsets of the underlying and immediate causes of death may be long (years) or short (seconds). In establishing the sequence of events preceding death, other conditions, designated as intermediate causes, are pathophysiologically sequenced between the underlying and immediate causes. Intermediate causes, if present, may number one or several, depending primarily on the length of time and complexity of events leading up to death.
Older literature has referred to the underlying cause of death as the "proximate cause", and the intermediate cause of death as the "intervening" cause. However, the terms "proximate" and "intervening" may have specific legal meaning that differs from the lay or medical usage, and it is recommended that the terms be avoided when discussing medical cause of death statements. The preferred terms are underlying cause of death, intermediate cause of death, and immediate cause of death.®MDSU¯ ®MDNM¯
A mechanism or mode of death is a physiologic derangement or a biochemical disturbance produced by a cause of death. The mechanism, because of its incompatibility with life, is the means by which cause exerts its lethal effect. A few examples of mechanisms are cardiorespiratory arrest, asystole, and respiratory arrest. Mechanisms lack etiologic specificity and are unacceptable substitutes for cause of death, and, in general, are not to be included in cause of death statements.
The manner of death explains the circumstances of how the cause arose. The manner of death is designated as either natural or unnatural. Natural deaths are due solely to disease and/or the aging process, while unnatural deaths are due to external causes (injury or poisoning) and include deaths due to intentional injury such as homicide and suicide, and deaths due to unintentional injury which are of an accidental manner of death. Deaths for which a manner has not, or cannot, be determined are classified as undetermined in manner.
The Death Certificate. Death certificates in use in the fifty states vary, but each is based on the U.S. Standard Death Certificate, which traditionally places responsibility for indicating the immediate, intermediate, and underlying causes of death on the attending physician, not the pathologist. As currently constructed, the death certificate instructions require the physician to select just one underlying as cause of death.
The attending physician's primary responsibility in death registration is the completion of the medical certification or cause of death section. This portion of the death certificate consists of two parts (Figure 2).
In Part I, the certifying physician is required to state a single condition, or a pathologically and etiologically related sequence of conditions (causes), that resulted in death. The condition temporally closest to death is stated on the first (top) line. Then one uses the causal concept of "due to or as a consequence of" to specify other antecedent conditions on progressively lower lines. These are listed one cause per line, with the underlying cause of death listed last. Depending on the state, on rare occasions, it may be necessary to add additional lines to Part I so that all conditions are entered with only one cause per line [10].
A single entry can be made in Part I if only one condition was present at death and was both the underlying and immediate cause [11]. Some examples include electrocution, anencephaly, ruptured cerebral arterial berry aneurysm, and drowning.
Part II of the medical certification section of the death certificate is titled "Other Significant Conditions." To be reported here are pre-existing or co-existing conditions that contributed to death but did not result in underlying cause of death in Part I. More than one "other significant condition" can be specified.
For decedents with long and complicated medical histories, selection of the underlying cause of death can be difficult. To accomplish this accurately, the medical history, clinical status, circumstances of death, and autopsy findings must be considered.
In general, death certificates for persons who die of unnatural manners of death will be completed by the local medical examiner or coroner, or under their authority. Be familiar with local death investigation laws, the death certificate form, and related policies and procedures.
Detailed background information and instructions for completing cause of death statements for natural deaths are contained in the Medical Cause of Death Manual published by the CAP, and in other sources[8,10].

FIGURE 2. PARTS I AND II OF THE
CAUSE OF DEATH SECTION OF THE DEATH CERTIFICATE®MDBU¯®MDNM¯

THE AUTOPSY PROTOCOL
AND THE CLINICOPATHOLOGIC SUMMARY.

Gross Autopsy Findings. Upon completion of the autopsy record, there should be an objective description of the observations in an appropriate format. The ordering of the description is of less importance than the need for consistency and completeness. Most often this component of the protocol follows the sequence: external examination; internal or in situ examination of the body cavities; and descriptions of the individual organs and tissues. Include weights and measurements as appropriate. Detailed descriptions of normal organs are of little value. It may be of value to include diagrams in the protocol. Organs that are examined after a period of fixation, such as the brain, may be described in a separate note.

Microscopic Findings. The extent of description of the histologic findings to be included in the protocol may vary. Make a record of the organs and tissues examined histologically. As in the case of the gross autopsy findings, confine microscopic notes to an objective record of observations. An index listing each glass slide and the tissue sampled is a requirement of the CAP.

Further Studies. Include any reports of microbiologic, chemical, histochemical, toxicologic and immunologic analyses; electron microscopy; cytogenetic studies; or any other studies performed on materials from the autopsy. If copies of photographs or radiographs are available but not included in the protocol, make a note of their existence and location.

Clinical History. Clinical history may be a part of the autopsy report, but it should be no more than a summary of factual material contained in the patient chart. Review of the chart and discussions with the attending physicians should be done prior to beginning the autopsy. Writing the summary enables the pathologist to address specific concerns and questions of the clinical staff regarding a patient's disease processes. Items to be considered include the following: age, gender, ethnic origin, occupation, established medical conditions and diagnoses, risk factors or characteristics pertinent to the disease processes identified, hospitalizations, surgeries, medications, and pertinent laboratory data.

Alternatively, the pertinent historical items can be incorporated into the clinicopathologic correlative summary (see below), rather than being written as a separate part of the autopsy protocol. In this case, general statements about the patient's clinical history can be used to introduce the clinicopathologic summary. Then, as each major disease process is discussed in greater detail, relevant medical history (including symptoms, physical findings, laboratory and other diagnostic studies, and therapy) may be incorporated.

Clinicopathologic Correlative Summary. A clinicopathologic summary can be described as an objective correlation of clinical findings with gross and microscopic findings and the results of other studies performed at autopsy to describe the death and to elucidate the sequence of events leading to death. A discussion of the underlying cause or causes of death and the immediate cause should be included in this summary.

Controversy has arisen over whether a clinicopathologic summary is to be included in the autopsy protocol, based on the nature of the autopsy report as a legal document. Interpretations of autopsy findings, critics say, can occur only when legal discovery proceedings have disclosed all there is to know about the decedent, his or her medical care, and the circumstances of dying. For this reason, it is of central importance to be objective in statements appearing in the clinicopathologic summary. Anyone reading an autopsy hopes to learn the the cause and manner of the patient's death. It is our opinion that a clinicopathologic summary built around objective documentation is an appropriate and important endeavor for the pathologist. Unfounded speculation and judgments regarding the abilities or actions of caregivers should be omitted from the clinicopathologic correlation.

INDEXING, CASE RETRIEVAL,
AND PUBLICATION OF AUTOPSY REPORTS.

Autopsy reports should be prepared in a such a manner that they can be indexed and retrieved both by the patient's name and by diagnosis, using computer software. The autopsy facesheet should contain the essential information required for indexing by diagnosis. For this reason, the autopsy facesheet, and preferably the entire autopsy report, should be prepared on a word-processor or laboratory information system. The computer-readable autopsy report should be available as single reports or as a collection of all reports, as appropriate, and should be stored in perpetuity. Commercial vendors may offer either natural-language or code-based indexing and retrieval capabilities as a part of their laboratory information systems.
In addition to institutional needs for case indexing and retrieval, the autopsy facesheet should be prepared in such a way that a summary of demographics and major diagnoses can be extracted from the facesheet for extra-institutional clinicopathologic, epidemiologic, and health-policy research, while protecting patient, care-giver, and institutional confidentiality. Autopsy facesheets should be downloadable as as ASCII (American Standard Code for Information Interchange) files. ASCII is a coding system in which all the alphabetic, numeric, punctuation, and common formatting characters are expressed as values between 0 and 127. Many commercial word processors and laboratory information systems employ idiosyncratic or proprietary formatting of text, but these systems usually have an option for downloading this text as ASCII files. Pathology departments should have the capability to transfer cases to offline personal computers, for conducting outcome studies.
An example of an autopsy database which is available to the public at large is the Internet Autopsy Database (IAD), a collection of over 49,000 autopsy facesheets contributed by over a dozen academic medical institutions [9,12]. This autopsy database is entirely in the public domain, and freely distributable. The IAD is available on the Internet worldwide web at Universal Resource Locator (URL): http://www.med.jhu.edu/pathology/iad.html.
The demographics section of the autopsy facesheet should contain two subsections: public demographics and private demographics. Public demographics should contain as much information as can be reasonably published for medical investigations, balanced against the need to protect patient confidentiality. The following demographics may be published: an encrypted patient identifier; the patient's age in years, with optional greater precision for pediatric autopsies; race/ethnicity; sex; year of autopsy; location; and occupation. It is possible to include these demographics, abstracted abstracted from facesheet records, in public databases without sacrificing patient confidentiality. As example, In the IAD the patient's public identifier are encrypted by a brokered encryption system which requires several persons or entities to decrypt, namely, the medical researcher requesting the patient's identity; the database administrator; the originating institution's Institutional Review Board; and a document attesting to informed consent by the next-of-kin [12].
The narrative-text portion of the autopsy facesheet should consist of four sections, all written as short sentences in medical English. These four sections are: CLINICAL HISTORY; ANATOMIC DIAGNOSES; CAUSE OF DEATH; and SUMMARY STATEMENT. The following guidelines conform to published guidlines for preparing computerized surgical pathology reports [13]. By following these guidelines, facesheets can be automatically (via computer) indexed and merged into a database [13,14].
1. The autopsy facesheet should consist entirely of short phrases or sentences in correctly-spelled English, to allow for computer encoding of diagnoses. Long sentences, sentences with dependent clauses, run-on sentences, and sentences with ambiguous negatives, tend to confuse some computer encoders.
2. Every sentence should have an unambiguous sentence-terminator, preferably period (.) followed by new-line (ASCII 13 followed by ASCII 10 in Windows/DOS systems). This seemingly trivial requirement has great practical importance. If the computer encoder can't ascertain the sentence-terminator, then diagnoses may become attached to the wrong body-site, or to no body-site at all. The period alone is NOT an unambiguous terminator, because it is used in in abbreviations (e.g., P.I.N., etc.), honorifics (Mr., Ms., Dr.), and numerals (12.5), which may appear in autopsy facesheets.
3. All medically-significant concepts in an autopsy facesheet should be translatable into a standardized nomenclature, such as SNOMED International. It is NOT necessary to write the autopsy facesheet with SNOMED nomenclature or SNOMED codes. It is preferable to write each autopsy facesheet in ordinary medical English, so that the autopsy facesheet can be recoded whenever SNOMED (or other standardized coding nomenclatures) undergo revision.
4. For the anatomical diagnoses, cause-of-death, and summary statement sections, every sentence must include an anatomic site (Topography) and a morphology or disease. (The clinical history section may contain symptoms not referable to a particular anatomic site, e.g., cachexia, malaise, fever, etc.). The body-site must be determinable by the computer-encoder from words within the same sentence. For example:
ACCEPTABLE: REFERS TO:
Cholecystitis. Gallbladder
Colovesical fistula. Colon, urinary bladder.

UNACCEPTABLE: REFERS TO:
Bladder calculus. Urinary bladder? Gallbladder?
Ventricular hemorrhage. Heart? Brain?
Cervical mass. Uterus? Neck?

COMPLETION OF REPORTS
According to current guidelines from the CAP, the written preliminary report must be submitted within two working days. The final report must be submitted within one month for routine cases and within three months for complicated cases [15]. The Joint Commission on Accreditation of Healthcare Organizations requires the provisional diagnoses to be recorded in the medical record within three days and the complete protocol to be made part of the record within 60 days unless exceptions for special studies are established by the medical staff [16]. If the anatomic diagnoses are preliminary, that fact should be indicated on the facesheet.
Several key dates must be included in reports, including the date that the preliminary list of anatomic diagnoses is released, the date that the final listing of anatomic diagnoses is released, and the date that the body of the autopsy (containing all the described components of the autopsy report) is released. The autopsy release date, also called the autopsy completion date, must be included. It is important that every institution that performs autopsies has a clearly defined concept of an autopsy release date, as there are legal, administrative, and medical consequences for any method by which the date is assigned. Pathologists who believe that the autopsy is not complete until every ordered test and study is completed, every clinical and pathologic consultation is collected, and every interpretive disagreement is resolved, are likely to have protracted autopsy turn-around times. It is easy to argue that autopsies are never complete, as additional diagnostic opportunities may arise that will cause cases to be re-examined years after the autopsy was begun. Despite the open-ended nature of autopsies, the CAP requires a 30 day turn-around for routine autopsies. Institutions may have their own standards that are shorter than CAP requirements. In our opinion, a more accurate and practical term than the autopsy completion date is the autopsy release date. The autopsy release date is the date that the pathologist releases all the completed autopsy findings, including the so-called Final Anatomic Diagnoses, into the medical record. Once the autopsy is released, supplementary reports may be added to the autopsy, but, in our opinion, the text of the released autopsy should not be changed.
Supplemental reports added to a released autopsy may consist of neuropathology findings, microbiology findings, discussions of issues raised at quality assurance conferences that refer to the autopsy, electron micrographs, even amended diagnoses. All supplemental reports should be dated. There will be occasions when the pathologist determines that an autopsy should not be released until further information is received, even when this lengthens the turn-around time of the autopsy. For example, the pathologist may decide that the cause of death cannot be determined without a full evaluation of neuropathology and special studies of brain slides. The pathologist might decide that it would be pointless and misleading to release the autopsy while these studies are still pending. In such cases, the pathologist should not feel obligated to release the autopsy. On the other hand, if the cause of death is apparent, the pathologist might release the autopsy report rapidly, and add the results of pending studies as supplemental reports, as they become available.
Occasions will arise when the pathologist wishes to modify an autopsy report. Once an autopsy is released, any modification must be added in a manner that insures that anyone reading the modified autopsy report understands that a modification has occurred, and also understands how the modified autopsy report differs from the original report. In the absence of such documentation, there may exist multiple and substantially different autopsy reports for the same patient issued by the same department, leading to regrettable legal and emotional consequences. In our opinion, the easiest way to deal with modifications of an autopsy report is with attached supplemental reports that leave the original released autopsy report intact. The pathologist responsible for the autopsy should sign the autopsy report. When a supplemental report is produced, it should become a part of the original report, along with all other supplemental reports issued for the case. The supplemental report(s) should be signed and dated by the responsible pathologist. The signature may take the form of an electronic signature (unique personal code), and this electronic signature should not be delegated to any other individual. Departments should develop a reliable method to insure the authenticity of all dates and signatures.
Distribution of the autopsy report is determined by local practice and applicable statutes within the jurisdiction. Many institutions regard the autopsy report as a component of the patient's medical record and, therefore, subject to the usual confidentiality considerations. Issues surrounding the confidentiality of HIV status on autopsy reports has been addressed by the Council on Ethical and Judicial Affairs of the American Medical Association, and their report should be consulted regarding questions in this area [17]. In brief, the council recommends that physicians maintain the confidentiality of HIV status on autopsy reports to the greatest extent possible, since this information is part of the medical record. However, pathologists must be aware of their reporting obligations to public health authorities and other parties at risk, as mandated under local law.

************************************************************************ FIGURE 4: SUGGESTED LETTER
Dear (name of individual who authorized the autopsy):
This letter is an expression of our sympathy at the recent death of your (relationship of the deceased to the letter recipient). We want to thank you for allowing the physicians of (name of health care institution) to perform an autopsy.
The autopsy examination is performed under the direction of the pathologists in (name of health care institution). This examination is designed to enable us to make a detailed analysis of the cause of death, the nature of the disease(s), and the effects of treatment. The information that this examination provides may be important in providing the patient's family and physicians with a better understanding of the cause of death and medical condition, and may aid in the advancement of medical science.
A preliminary report of the autopsy findings will be sent to your physician (physician's name), in (physician's city {physician's office phone number}) within a few days. The final detailed report, however, must await the results of microscopic examinations, a review of your (relationship of deceased to the letter recipient) illness or condition and special studies when indicated. This final report will also be sent to your physician upon completion. The results of the autopsy may be discussed with your physician or, if you desire, with us.
Sincerely,

The members of the College of American Pathologists' (CAP) Autopsy Committee who prepared this guideline are Peter B. Baker, MD, The Ohio State University, Columbus; Kevin E. Bove, MD, Childrens Hospital Medical Center, Cincinnati, Ohio; Arthur B. Chandler, MD, Medical College of Georgia, Augusta; Gregory J. Davis, MD, Bowman Gray School of Medicine, Winston-Salem, NC; Richard C. Froede, MD, Armed Forces Institute of Pathology, Washington, DC; Stephen A. Geller, MD, Cedars-Sinai Medical Center, Los Angeles, Calif; Randy Hanzlick, MD, Emory School of Medicine, Atlanta, Ga; Kathleen Heidelberger, MD, University of Michigan Hospitals, Ann Arbor; Rolla B. Hill, MD, Philo, Calif; Grover M. Hutchins, MD, The Johns Hopkins Hospital, Baltimore, Md; L. Tobias Kircher, MD, Penrose Hospital, Colorado Springs, CO; Bruce M. McManus, MD, PhD, St. Paul's Hospital, Vancouver, BC, Canada; J. Conor O'Keane, MD, Boston (Mass) University School of Medicine; Hans J. Peters, MD, St. Francis Hospital, Columbus, Ga; James M. Powers, MD, University of Rochester (NY) Medical Center; J. Thomas Stocker, MD, Armed Forces Institute of Pathology, Washington, DC; Ellen D. Wallen, MD, East Tennessee State University, Johnson City; Louis H. Weiland, MD, Mayo Clinic, Scottsdale, Ariz; and Nancy Young, MD, Hahnemann University Hospital, Philadelphia, Pa.

REFERENCES.

1. Hutchins GM and the Autopsy Committee of the College of American Pathologists: Practice guidelines for autopsy pathology: Introduction. Arch Pathol Lab Med. 1994;118:18.

2. Hutchins GM and the Autopsy Committee of the College of American Pathologists. Practice guidelines for autopsy pathology: Autopsy performance. Arch Pathol Lab Med. 1994;118:19-25.

3. Hutchins GM and the Autopsy Committee of the College of American Pathologists: Practice guidelines for autopsy pathology: autopsy reporting. Arch Pathol Lab Med. 1995; 119:123-130.

4. Powers JM and the Autopsy Committee of the College of American Pathologists: Practice guidelines for autopsy pathology: autopsy procedures for brain, spinal cord, and neuromuscular system. Arch Pathol Lab Med. 1995; 119:777-783.

5. Bove KE and the Autopsy Committee of the College of American Pathologists: Practice guidelines for autopsy pathology: perinatal and pediatric autopsy. (submitted for publication).

6. PHS Form 398, race/ethnicity document.

7. Kircher T, Anderson RE. Cause-of-death. Proper completion of the death certificate. JAMA. 1987;258:349-352.

8. Hanzlick R and the Autopsy Committee of the College of American Pathologists. Practice Guidelines for Writing Cause of Death Statements. Northfield, Ill: College of American Pathologists; (in press).

9. Moore GW, Berman JJ, Hanzlick RL, Buchino JJ, Hutchins GM. A prototype international autopsy database: 1625 consecutive fetal and neonatal autopsy facesheets spanning twenty years. Archives Pathol Lab Med 120:782-785, 1996

10. National Center for Health Statistics: Physician's Handbook on Medical Certification of Death. U.S. Department of Health and Human Services, Public Health Service, Hyattsville, Md, 1987; DHHS Publication No. (PHS)87-1108).

11. Physicians' Handbook on Medical Certification: Death, Birth, Fetal Death. Hyattsville, Md: National Center for Health Statistics; 1978. US Department of Health and Human Services publication (PHS) 81-1108; 6-15.

12. Berman JJ, Moore GW, Hutchins GM. Maintaining patient confidentiality in the public domain internet autopsy database. Journal of the American Medical Informatics Association (JAMIA), Symposium Supplement, pp 328-332, 1996.

13. Berman JJ, Moore GW. SNOMED-Encoded surgical pathology databases: a tool for epidemiologic investigation. Modern Pathology 9:944-950, 1996.

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15. ////needs to be updated/// Commission on Laboratory Accreditation. 1992 Inspection Checklist Section VIII: Anatomic Pathology and Cytopathology. Northfield, Ill: College of American Pathologists; 1992.

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PMID: 12234714.
PubMed Entry
Full Text of Article:
http://www.netautopsy.org/uniqmddm.htm

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Chapter 4. In: Cios KJ. Medical Data Mining and Knowledge Discovery. Berlin: Springer Verlag. 2000;4:61-107.
ISBN: 3-7908-1340-0, 502 pages.
Published within the series: "Studies in Fuzziness and Soft Computing", Physica-Verlag Heidelberg, a Springer-Verlag Company.
Full Text of Article:
http://www.netautopsy.org/apdmchap.htm

Last updated: 9/15/2005, by G. William Moore, MD, PhD.