Autopsy Report (Hospital/Non-Forensic)

Case Information

Institution: [Facility name]
Autopsy Case Number: [Case number]
Report Type: Hospital Autopsy (Non-Forensic)
Decedent Name: [Full name]
MRN: [Medical record number]
Date of Birth: [DOB] Age: [Age]
Sex: [Sex]
Date/Time of Death: [Date and time]
Location of Death: [Location]
Date/Time of Autopsy: [Date and time]
Date of Report: [Date]
Report Status: [Final / Provisional] (If Provisional, list pending items.)
Authorization: [Type of authorization and any restrictions or limitations on examination scope]
Autopsy Type: [Complete / Limited / Organ-focused] (Specify anatomic scope and any exclusions.)
Attending Pathologist: [Name, credentials]
Prosector(s): [Name(s), credentials]

Clinical Questions

(List 1–5 concise, specific questions driving the autopsy.)

• [Clinical question 1]
• [Clinical question 2]
• [Additional clinical questions as applicable]

Major Diagnoses

(Prioritized list of final anatomic diagnoses using concise diagnostic phrasing. Any diagnosis in Cause of Death must appear here.)

• [Diagnosis 1 – organ/system and key pathologic process]
• [Diagnosis 2 – organ/system and key pathologic process]
• [Additional diagnoses as applicable]

Cause of Death

(Use death-certificate format. Avoid mechanism-only phrases without etiologic disease. Include time intervals when known; otherwise state Unknown.)

Part I (Causal Chain):

Line a. Immediate cause: [Immediate cause of death] — Interval: [Interval / Unknown]
Line b. Due to: [Intermediate cause] — Interval: [Interval / Unknown] (Omit if not applicable.)
Line c. Due to: [Underlying cause] — Interval: [Interval / Unknown]

Part II: [Other significant conditions contributing to death but not in the causal chain] (State None if none identified.)

(If uncertainty exists, use qualifiers such as probable or presumed. If undetermined, state Undetermined and explain in Clinicopathologic Correlation.)

Clinical Summary

[Concise narrative including: reason for autopsy request; pertinent medical/surgical history; terminal hospitalization timeline with presenting problem and major diagnoses; key procedures and interventions; high-yield imaging and laboratory trends; circumstances of death] (If history is limited, state the reason.)

External Examination

(Report objective observations only. Avoid causal or mechanistic speculation.)

• Identification and body condition: [Body length, weight, habitus, nutritional status]
• Postmortem changes: [Livor distribution/fixity, rigor status, decomposition] (Include only if pertinent.)
• Medical interventions and devices: [Lines, tubes, airways, drains, surgical incisions, implanted devices with locations]
• Skin and soft tissues: [Edema, ulcers, rashes, jaundice, ecchymoses, wounds with size and location]
• Other notable findings: [Additional pertinent external observations] (Include only if applicable.)

Summary: [One-sentence factual summary of overall external condition]

Internal Examination – Gross Findings

(Maintain consistent organ-system order. Include weights and key measurements. Document pertinent positives and negatives that address clinical questions. Use concise statements such as No significant gross abnormalities when unremarkable. For unexamined systems, state Not examined due to [reason].)

• Body cavities and serosal surfaces: [Pleural, pericardial, peritoneal cavities; effusions with type/volume; adhesions]
• Cardiovascular system: [Heart weight; chambers; wall thickness; valves; coronary arteries with stenoses; aorta; grafts/stents]
• Respiratory system: [Lung weights; airways; parenchyma; pulmonary arteries; pleura]
• Hepatobiliary and pancreas: [Liver weight and cut surface; bile ducts; gallbladder; pancreas]
• Gastrointestinal tract: [Esophagus to rectum; luminal contents; mucosal lesions; surgical alterations]
• Spleen: [Weight; capsule; parenchyma]
• Genitourinary system: [Kidney weights; cortex/medulla; collecting systems; bladder; reproductive organs]
• Endocrine organs: [Thyroid; adrenals; pituitary; others as examined]
• Hematolymphoid system: [Lymph nodes; marrow appearance; thymus if relevant]
• Musculoskeletal system: [Skeletal muscle; bones; joints] (Include only if relevant.)
• Central nervous system: [Brain and spinal cord gross findings] (If brain retained for fixation, state: Brain retained; gross description deferred to addendum.)
• Other organs/tissues: [Additional specimens such as transplanted organs or surgical sites]

Microscopic Findings

(Document in same organ-system order as gross findings. Provide salient histologic observations with diagnostic interpretation. Note limitations such as autolysis.)

• Cardiovascular: [Histologic features and interpretation]
• Respiratory: [Histologic features and interpretation]
• Liver/biliary/pancreas: [Histologic features and interpretation]
• Gastrointestinal: [Histologic features and interpretation]
• Spleen: [Histologic features and interpretation]
• Genitourinary: [Histologic features and interpretation]
• Endocrine: [Histologic features and interpretation]
• Hematolymphoid: [Histologic features and interpretation]
• Musculoskeletal: [Histologic features and interpretation] (Include only if examined.)
• Central nervous system: [Histologic features and interpretation] (If pending fixation, state: Pending; to be reported in addendum.)
• Other: [Additional tissues examined]

Histology limitations: [Autolysis, fixation quality, sampling constraints] (State None if none.)

Ancillary Studies

(Include specimen source, results, and reference ranges. For pending results, list items and note addendum to follow.)

• Toxicology: [Specimen source, analytes, results, reference ranges]
• Microbiology/Virology: [Specimen source, organisms/assays, results]
• Clinical chemistry: [Vitreous electrolytes, glucose, ketones, other]
• Genetic/Molecular studies: [Tests, rationale, results or pending]
• Postmortem imaging: [Modality, key findings]
• Other studies: [Additional ancillary tests]
• Pending studies: [Pending items; results will be issued as addendum]

Block/Slide Catalog

(Required when histology performed. List block identifier and tissue source; note special stains if applicable.)

• [Block ID]: [Tissue source]
• [Block ID]: [Tissue source]
• [Additional blocks as applicable]

Clinicopathologic Correlation

(Interpretive synthesis answering clinical questions. Avoid commentary on quality of care.)

• Responses to clinical questions: [Answer each question with supporting findings]
• Causal chain: [How findings support the immediate, intermediate, and underlying causes of death]
• Discrepancies: [Major differences between clinical diagnoses and autopsy findings] (State None if none.)
• Limitations: [What cannot be concluded and why]

Retained Materials

[Organs, tissues, or fluids retained beyond routine blocks and slides; reason for retention; expected disposition per institutional policy] (Omit section if none retained.)

Authentication

Pathologist Signature: [Name, credentials, signature]
Date/Time of Final Sign-out: [Date and time]
Co-signature: [Name, credentials, signature] (Include if trainee involvement requires co-signature.)

Addendum

(Include when pending results return, neuropathology completed after fixation, or corrections required. Omit section if not applicable.)

Addendum Date: [Date]
Author: [Name, credentials]
Reason: [Pending study results / Neuropathology after fixation / Correction]
New Information: [Results or findings]
Interpretation Updates: [Changes to Cause of Death, Major Diagnoses, or conclusions]