Transcribing Autopsy Reports
Autopsy and Medical Transcription
Each specialty in medicine has its own "usual" set of vocabulary words though there can be quite a bit of overlap between specialties. For instance, one would expect to find at least some of the terminology for cardiology under pulmonary medicine simply because quite often there is an intertwining of the mechanics of the body concerning both systems. There can also be some crossover between these two body systems when referring to the heart and conditions affecting this organ.
Autopsy is one specialty of clinical medicine where the unseasoned MT may find a few stumbling blocks. While this specialty's terminology can be found in the pathology sections of some medical dictionaries, terminology can be very trying when attempting to learn the "lingo" of autopsy.
This author, as an online instructor for medical terminology, has found it very frustrating to steer students to reliable resources specifically for transcription of autopsy reports. Some transcription services offer internships in this specialty of medicine which is highly technical and considered to be level 2 material by most.
Understanding the purposes of autopsy and the language of medicine surrounding it go a long way to preparing students and MTs alike for transcribing reports. Contrary to most people's conceptions, all autopsies are not created equal.
There are basically two different types of autopsies though each can be performed in an abbreviated fashion or an extensive fashion. The two types differ because the circumstances surrounding death are different.
Clinical Autopsy. This is the kind of autopsy performed when someone dies in a hospital and there is a question as to the cause of death. For instance, a patient who was seemingly fine and recovering after surgery but suddenly has a cardiac arrest and dies. The result is "probably" a pulmonary embolism but an autopsy needs to be done to confirm this.
Forensic Autopsy. This is the kind of autopsy performed on an unidentified person found dead in the woods, an identified person found three days after he or she died in their home, or the kind of autopsy performed on a stabbing victim or a gunshot victim. The details of the autopsy are usually very thorough and may also include evidence brought in with the body such as personal effects or things found at the scene of the crime. The evidence and manner of death can be used as substantiation in criminal cases and must be thoroughly documented.
What Autopsies Tell Us
In the simplest terms, autopsies give us the following information:
- What. What killed the person
- When. When did the person die--today or last week?
- Why. Were there contributing injuries or conditions?
The manner of death is also of great importance and is always one of the following:
Anatomy of an Autopsy Report
Most autopsy reports today follow a format. This format may vary depending upon the institution but they mostly contain relatively the same basic collection of information.
It should also be noted here that medical examiners can perform autopsies (and usually do) but coroners can also perform them. Unlike medical examiners (who are usually physicians with a background in forensic pathology), coroners may be the local gas station mechanic in a rural area with medical background but not a physician. Most coroners are physicians but in some cases, autopsies are relegated to someone who has another full time job. Their reports of course would probably be less technical than say a medical examiner's in New York City.
Basic components of the autopsy report (most will be part of every report):
- Autopsy Face Sheet. General information such as cause of death.
- Historical Summary. Details of what occurred before the person's death.
- Examination Type, Date, Time, Place, Assistants and Attendees. Specifics of the exam.
- Presentation, Clothing, Personal Effects, Associated Items. How the body arrived.
- Evidence of Medical Intervention. Intubation, defibrillation, cardioversion, etc.
- Postmortem Changes. Rigor mortis, livor mortis, putrefaction, etc.
- Postmortem Imaging Studies. CT or MRI to determine if autopsy is necessary.
- Identification. Scars, tattoos, surgical scars, height, weight, etc.
- Evidence of Injury. Gunshot wounds, knife wounds, broken bones, etc.
- External Examination. Condition of the body (which affects funeral arrangements).
- Internal Examination. Inspection of organs for signs of disease, trauma, etc.
- Histology Cassette Listing and Microscopic Descriptions. Samples taken and logged.
- Toxicology, Lab and Ancillary Procedure Results. Labs run to determine results
- Pathologic Diagnoses. Diagnoses organized by anatomic system.
- Summary and Comments. Correlates all the above and determines cause of death
- Cause of Death Statement. Includes face sheet findings and determines main cause.
External Examination Second-Level Headings
Some reports will be broken down by headings noted below to more clearly define findings on an external examination. These are generally more common in forensic autopsies.
- General: discoloration, odor, hydration, body habitus and hair distribution
- Head: findings in scalp, forehead, nasal cavity, mouth, etc
- Neck: masses, scars, abrasions, contusions, marks such as ligature marks
- Torso: breasts, genitals, inguinal regions, torso front and back, buttocks
- Upper Extremities: elbows, wrists, forearms, fingers, hands
- Lower Extremities: thighs, knees, legs, ankles, feet and toes
- Evidence of Injury: detail of external injuries or absence of injury
- Summary: overall findings of external examination
Internal Examination Second Level Headings
Likewise, sometimes in more thorough autopsies, the internal examination will be broken down into headings to more easily note findings in an organizational manner.
- Torso: describing pelvic, abdominal, thoracic organs/tissues (see below)
- Head: describing brain, dura, scalp, skull, etc
- Neck & Pharynx: describing neck vessels, tongue, pharynx, etc.
- Spinal Column & Cord: describing cord and spinal column if necessary.
- Additional Dissection: describing specific areas such as a placenta or muscle.
Due to the large size/category of the torso, there may be so-called third-level headings for just the torsom such as:
- Evisceration/Dissection Method: how organs were removed.
- Chest Wall, Abdomen Walls and Cavities: ribs, peritoneal cavity, etc.
- Organ Weights: how much each organ weighed in grams.
- Cardiovascular System: description of heart and vessels.
- Respiratory System: description of lungs, diaphragms, etc
- Digestive System: description from stomach to anus.
- Hepatobiliary System: description of organs such as liver, gallbladder, etc.
- Reticuloendothelial System: description of lymph nodes, spleen, bone marrow, etc.
- Urogenital System: description of bladder, kidneys, reproductive organs, etc.
- Endocrine System: description of thyroid, parathyroid, adrenal glands, etc.
Importance of the Autopsy Report
For whatever reason an autopsy is deemed necessary, the report of autopsy is a vital and final piece of information in a person's life. Autopsies can be done for many reasons and while most MTs find transcription of autopsy reports rather depressing, this particular medical record report serves a very vital function in today's medical community.
Consider these points:
- Autopsies are not done on everyone who dies in a hospital: the resumed reason dictates.
- An autopsy can provide closure to a family when someone dies suddenly.
- Forensic autopsies can determine many factors: suicide versus homicide.
- Medical conditions or injuries are often unknown but discovered by an autopsy.
- Medical research is benefited directly by an autopsy.
What MTs Should Know About Autopsy Reports
In addition to the detailed formatting as noted above, a medical transcriptionist should be aware of these needed assets when typing autopsy reports:
- Strong knowledge or research ability for anatomy and physiology is needed.
- Pathological medicine terminology resources are a must.
- Sample reports of autopsy are of great help in understanding terms.
- Knowledge of toxicology and/or lab terms is most helpful.
- Likewise knowledge of radiology terminology is a big plus.
Starting out, especially when just out of school, an MT may become overwhelmed when typing autopsy reports. Again, it should be noted that autopsy transcription is considered by most Level 2 criteria (as determined by AHDI—Association for Healthcare Documentation Integrity), which means this is more sophisticated material and outside the usual realm of the novice MT.
That being said, with diligence and adequate resources and samples, most MTs can assimilate this specialized language of medicine. However, it does require much research and consistent exposure to become skilled in this particular branch of medical transcription.
It is most helpful for MTs to find reliable and credible terminology resources. Another adjunct to learning is to watch videos and presentations from reliable sources.
In any type of medical transcription situation, the standard rule is to keep learning, keep thinking and most of all, keep researching and it will get easier as time goes on. Especially in such a technical arena such as the specialty of autopsy, MTs who are qualified are much needed.
Watch the video below for a look at how imaging can aid in the autopsy process.