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Autopsy Report Basics: An Easy-to-Understand Guide

Tom May
Pathologist preparing for autopsy

Although glamorized by television and the movie industry, there is still a great deal of uncertainty and confusion about the need and purpose of performing an autopsy and writing an autopsy report. The expensive autopsy procedure determines the cause of death, produces documents for legal purposes, and generates information used for education and research. Understanding the process of producing an autopsy report gives insight into its meaning and value.

What Is an Autopsy Report?

An autopsy report is a detailed explanation of the finds of an autopsy, the procedure which thoroughly examines the body of the deceased in order to determine the exact cause of death. If an autopsy is required, the process is both medical and legal. The exact laws for an autopsy vary in each state. Once the autopsy is complete, the pathologist writes an official report. The report will show an exact cause of death and how they think it happened.

Autopsy Report

Autopsy Report Contents

The contents of an autopsy report record all the investigative procedures and evidence with regard to the death of an individual. The report stresses the relationship between the medical findings and the pathological findings. The report summarizes all information about the individual's death. The report may take a number of weeks to complete, depending upon the type of toxicology reports needed.

Autopsy Report Format

An autopsy report follows a general format approved by the National Association of Medical Examiners. The appearance differs by state, but the information contains the following.

Diagnosis

Medical records are an important component in an autopsy investigation. In addition to medical history, the records can include mental health issues, prescription and medication history, as well as family and social history. What seems like a simple fall and head injury may be seen in light of a history of falls and consequences.

Toxicology Reports

Some of these findings are available almost immediately, but some may take weeks to perform and record.

Opinion

This section includes a summary of initial observations and conclusions. The conclusions in this section often dictate what additional investigations are necessary.

Circumstances of Death

The autopsy findings will have a Cause of Death (this includes factors contributing to the death like "blunt force trauma"); Manner of Death (natural, accidental, suicide, homicide and undetermined); and the Mechanism of Death (this notation will mention stab wounds, gunshot wounds, or drug overdose).

Personal Identification Information of the Decedent

Contains vital statistics.

General Description of Clothing and Personal Effects

This section is self-explanatory.

Evidence of Medical Intervention

This part of the report mentions evidence from previous surgical procedures and prescribed medications.

External Exmaination of Body

The external examination covers the body from head-to-toe and includes location, measurements and notations of all wounds, scars, marks, tattoos and conditions of the body and structure.

Internal Examination of the Body

This is usually what is thought of when an autopsy is described. This examines the surgical procedures for the removal and examination of the organs. It can also include assessment of bullet trajectories and other factors noticeable. Pictures of the findings may be included for future reference. Tissues may be frozen, and on occasion entire organs are preserved.

Samples Obtained

This part of the report details what samples were taken and the eventual results of the findings.

Pathologist taking a sample for analysis during a autopsy

Are There Different Types of Autopsies?

An autopsy is a thorough examination of the body of a dead person. It is also known as a "post-mortem examination" or "necropsy." The word autopsy comes from a Greek word that means "to see with one's own eyes." A medical examiner or pathologist is usually the one who performs an autopsy. A coroner is an elected official who may not be a medical doctor. The coroner would work with a pathologist. Autopsies may be performed for medical or legal purposes. There are several types of autopsies.

  • A complete autopsy examines the entire external body, along with an internal investigation of all the major organs of the body.
  • A partial autopsy examines the entire external body, but limits the examination of the internal organs to certain parts of the body.
  • A clinical autopsy determines exactly how the person died and evaluates the disease and the treatments of the disease. It can be used for research and training purposes.
  • A forensic autopsy is carried out when a criminal investigation is proceeding.
  • On very rare occasions, an exhumation autopsy is performed after the body has been buried.
Corpse lying in the morgue

Who Can Request an Autopsy Report?

The state mandates an autopsy be performed under certain circumstances, especially when the death seems suspicious. An autopsy report can be requested by several individuals or organizations.

Coroner or Medical Examiner

The coroner or medical examiner can order an autopsy report without the permission of the family. Deaths that are often investigated include:

  • Suspicious death involving a crime
  • Death that occurs as the result of an accident or a suicide
  • Unexpected death where the person appears to be in good health
  • Death that occurs within 24 hours of admission to a hospital
  • Death that occurs during an operation or other medical procedure
  • Death that occurs when the person is in the custody of the police

Hospital or Research Institution

Hospitals or educational facilities often request an autopsy report. When they do so, permission must be obtained from the next of kin. The family has the right to refuse the request, or to limit its scope or nature. Doctors may request a report to confirm the accuracy of a diagnosis or the effectiveness of a drug or device. Educators request autopsy reports to further medical research and to train new doctors.

Next of Kin

The family can request an autopsy report for a number of reasons. Findings may benefit the family on a practical level, or it may help answer questions and provide closure and peace of mind to the circumstances of the death.

Can an Autopsy Report Provide Comfort for the Grieving?

An autopsy report can help provide closure for families by helping them understand the cause of death. Families may want to know, "How far did the cancer spread?" or "Was my loved one given proper treatment?" The autopsy eliminates many lingering questions and uncertainties. In addition, the report can provide for the family:

  • Prompt release of a death certificate, which allows life insurance benefits to be issued
  • Assurance that appropriate care was given, satisfying worries or guilt
  • Information about genetic diseases that might affect other family members
  • Understanding of environmental factors which might have contributed to the cause of death that might affect other family members
  • Satisfaction and peace that the autopsy may assist others suffering from the same condition while helping in medical education and research
Blank Death Certificate tucked in a yellow manila envelope

How Long Does an Autopsy Take?

Most standard autopsies take about two to three hours. Complicated circumstances may take a bit longer, but even then, the autopsy should not delay either the viewing of the body or the funeral service. Once the report is submitted, the body is transported to the funeral home. Funeral directors hide or mask the signs of an autopsy with make-up and clothing. An autopsy usually does not interfere with any funeral arrangements the family may make.

Reading the Autopsy Report

Understanding the information in an autopsy report provides a complete picture of the death of an individual. Knowing what is in the report and how it is formatted is crucial for understanding its contents. Reading an autopsy, even for a non-professional individual, can help discover hereditary illnesses and provide peace of mind after the death of a loved one.

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Autopsy Report Basics: An Easy-to-Understand Guide