IMPORTANT PAPERS CONNECTED WITH AN AUTOPSY

The prosector must be familiar with the form and substance of three documents:

    1.    The AUTOPSY PERMIT form.
    2.    The PROVISIONAL ANATOMIC DIAGNOSIS.
    3.    The (final) AUTOPSY REPORT.

     The AUTOPSY PERMIT must be properly completed and signed by the two appropriate parties (i.e. next of kin and a clinical physician or his/her representative, plus an additional witness for telephone permits) before the autopsy starts. The responsibility for a valid permit in the first instance is that of the person who performs the autopsy. Autopsy is not to be started until the prosector has the permit in hand. The only exception to this is in cases where the permission is granted by the Medical Examiner to the Pathology Department or the prosector by telephone.

     The PROVISIONAL ANATOMIC DIAGNOSIS must be prepared as soon as gross examination is complete and after gross findings are reviewed by the staff member. It is then immediately typed and sent to appropriate parties.

     The final AUTOPSY REPORT is essentially a laboratory report to the physicians who took care of the patient. As such, its value is a function of promptness of preparation. It includes the final Anatomic Diagnosis, complete descriptions of the gross, and usually the microscopic general findings, descriptions of the gross and microscopic neuropathologic findings. Completion of the final autopsy report within 30 working days of the beginning of the autopsy is strongly recommended. Results of special studies, as well as results of examination of the central nervous system, can be reported in addenda to the final autopsy report. If the definitive diagnosis cannot be completed (typed and signed) within 30 days, the prosector is responsible for so notifying the medical Records Department before that time.