Authors: Alex K Williamson MD & Meagan Chambers MD
Reviewing a decedent’s available medical record and synthesizing the information into the Clinical Summary is an integral component of competent autopsy performance and reporting. This process is vital to an autopsy’s addressing relevant clinical issues and optimizing resources, reporting, and quality assurance initiatives. The amount of information available for review will vary among referring institutions, but in each case, a thoughtful review of the available medical record should be performed prior to a resident’s discussing the case with the attending pathologist and performing the autopsy.
- Verify Emergency Contact and next of kin information to aid/confirm the consent process
- Review their problem list and note relevant outpatient and inpatient diagnoses (i.e., those related to the final hospitalization, as well as chronic conditions)
- Review lab results Tab and note trends over the course of the final hospitalization
- Hematology (e.g., WBC, Hgb, Plt)
- Coagulation (e.g., PT, PTT)
- Chemistry (e.g., creatinine, BUN, AST/ALT, A1C, troponins, BNP
- Urinalysis (e.g., protein, leukocyte esterase, casts)
- Immunology (e.g., hepatitis serologies)
- Microbiology, including cultures (note date and specimen site)
- Anatomic Pathology (should also be checked in Cerner)
- Other testing
- Review procedures and note relevant procedures (also see Procedure Notes, below)
- Review imaging and note relevant imaging studies and their findings
- Review cardiology results and note relevant imaging and/or electrophysiology studies and their findings
- Review scanned documents/media
- Review clinical notes (not just the discharge note):
- Review initial H&P Note
- Chief complaint/recent history
- Review all Consultation Notes
- Note any disorders and their treatment(s)
- Note problem list and how the problem(s) evolve over time
- Review all Procedure Notes
- Note any relevant complications, resultant pathology specimens, or altered anatomy to be encountered at dissection
- Review initial H&P Note
Synthesize the above information into the Autopsy Clinical Summary section of the autopsy report.
After the clinical review is performed the resident should discuss the case with the attending pathologist. The resident and attending can then decide on their approach to the autopsy, including assessing the need for any ancillary studies or special procedures.
Additional Comments
- A similar process should be followed for neuropathology and brain cutting, as well, with emphasis on neuropsychiatric history (e.g., stroke, dementia) and neuroimaging studies and findings.
- For fetal deaths, the clinical summary should include a review of the mother’s medical and obstetric history, as above, and the delivery note.
- For neonatal deaths, the clinical summary should include a review of the mother’s medical and obstetric history, the delivery note, and the baby’s medical record, as above.
