How to Finalize the Autopsy Report

Dr. Cameron Wood asked you to finalize the Autopsy Report for the Herren case, revising the Opinion section so it explains the cause the death in terms that various types of readers can easily understand. Your goal is to ensure that readers are able to understand thoroughly your investigation, your conclusions about the cause of death, and all relevant contributing factors. Readers will want to make sense of Nick’s death, both why and why now. This Step-by-Step Guide will help you write a thorough account of the case that leaves no questions unanswered.

You are not a medical professional, so you are not expected to use technical medical language beyond what you are able to understand when writing your report. You should provide a thorough analysis that is clear and easy to follow.

Get Organized

1. Review the email from Dr. Wood. It may be helpful to print the email and highlight the important points. Make sure you understand what Dr. Wood expects you to do to complete this task.


2. Open the Guide to Writing Autopsy Reports available in the Resources section. This will give you the most thorough explanation of how to write the final version of the Opinion section.


3. Download and review the attached Final Draft of the Sample Autopsy from the Lawson case from Dr. Wood’s email to get a sense of where you are headed in this task . Take time to familiarize yourself with the content and style of the Opinion section. Read Dr. Wood’s comments within the sample autopsy report (focusing on the Opinion section in particular) for guidance about the content and level of detail you should use in your final report.


4. Refer to your earlier notes and the Resources available to guide you as you finalize your report. For example, your Research Notes from Task 2.3 Prioritize the Differential Diagnosis may provide useful information about the clinical findings for AVM and other details related to your investigation. You may also refer back to the Resources for earlier tasks for information related to contributing factors.


5. Revisit the Pathologic Diagnoses and Opinion sections of your latest draft of the Autopsy Report for the Herren case to refresh your memory of your analysis of the decedent’s cause of death.


6. Meet with your team to decide how you will complete your work.


7. Contact your mentor with any questions about your assignment.

Finalize the Opinion section

Your objective is to tell the decedent’s story in a way that non-expert readers (e.g., the police or the family) would understand. It’s not nearly enough to state that the cause of death was a ruptured AVM. You have to provide answers to the follow-up questions readers would naturally have about the circumstances and reasons behind the death.

Remember: refer to the Guide to Writing Autopsy Reports for a detailed explanation of how to write this section. It’s the best set of instructions for you to follow.

1. Clearly state the cause of death in this case. In the opening of the Opinion section you should write a simple statement of the cause of death. This is not where you go into a deeper explanation about it. You will do that later in this section.


2. Provide the context of the death. This is where you “tell the story” of the events surrounding the death. Write out what led up to the death, any known associated circumstances, and any related historical information about the decedent.


3. Thoroughly explain the medical story of the death. This should provide your detailed analysis of what happened, why it happened, why now, and how you figured it out. Here you should thoroughly cover all elements discussed in the Guide to Writing Autopsy Reports.


4. Summarize key findings related to the cause of death in this case. Although you may have covered some or all of these elements in what you have already written, for your conclusion, you should restate key findings related to the following (for definitions of these terms refer to the Guide to Writing Autopsy Reports):
   
   
• definition of the cause of death


• epidemiology and etiology


• pathogenesis


• manifestations


• laboratory findings


• prognosis


• treatment.


5. Ensure that you write the Opinion clearly so that it is easy for non-experts to understand. Write in complete sentences and explain any technical terms so that non-medical professionals will be able to comprehend them.

   Note that you may have already covered much of what’s required in the Opinion section in earlier drafts of your report. The point now is to do two things, 1) make sure you’ve completely covered all required points, and 2) make sure it no longer looks like rough notes. It needs to be clear, well-organized prose that flows well and is easy to follow.

Review your work.

Refer to the Opinion section of your final Autopsy Report.

1. Did you write a thorough explanation of the cause of death and contributing factors, including:


• definition of the cause of death


• epidemiology and etiology


• pathogenesis


• manifestations


• laboratory findings


• prognosis


• and treatment.


2. Does your Opinion section address any questions readers might have about the cause of death, especially if such a death was unusual?


3. Did you write the Opinion section in a professional manner that is easy to follow (e.g., complete sentences, well structured, terminology explained as appropriate)?

Submit your work.

1. Make sure all team members sign off on the final Autopsy Report.


2. Review the checklist located in the Submit your work section of this task, and submit your work to your mentor.

NOTE: You may refer to Resources from earlier tasks as needed to complete your research.

Medical Process

Guide to Writing Autopsies – Guidelines for the appropriate content to include (or not include) when drafting your Autopsy Report.

Autopsy Procedure – A detailed description of autopsy procedures.

Arteriovenus malformation

Arteriovenus malformation (AVM) - A comprehensive overview of AVM including causes, symptoms, and diagnosis.

Risk factors increasing chances of AVM

Illustrated overview of AVM