**APPENDIX B7**

## Preparation of the Autopsy Protocol {#preparation-of-the-autopsy-protocol .unnumbered}

The autopsy protocol is a systematic objective description of the
postmortem pathologic findings, which are interpreted and correlated
with the clinical findings. It should be concise, and diagnostic terms
should be avoided in the gross description. Clarity should be the aim.
In general, avoid cliches and unusual descriptive terms.

Ordinarily, each organ is described separately. However, if a tumor
involves several organs by local extension, it may be desirable to
describe it under one appropriate heading rather than separately under
each organ. The original description may be referred to subsequently.

Write the provisional diagnoses and the immediate cause of death on the
*day* of the autopsy and dictate the Provisional Anatomic Diagnoses
(PAD) immediately. The final signed PAD must be in medical records
within 72 hours. During the week, if dictation is finished by 4:00 p.m.,
the PAD will be delivered before 11:00 a.m. the next morning. (Dictation
must be *COMPLETED, NOT STARTED* by 4:00 p.m.). The PAD for Friday cases
must be dictated before 4:00 p.m. on Sunday so the report will be
delivered by Monday. The clinical summary and gross description should
be written and dictated within 24 hours, before details are forgotten,
and the tissue blocks should be submitted to histology 24 hours after
the dissection. The microscopic findings should be described and
reviewed with a staff pathologist within 4 weeks and the final report
completed within 6 weeks. At 60 days, the final reports become overdue.
Because it takes up to a week for final typing, corrections, and
signatures, the final reports should not be submitted to the autopsy
secretary at the last minute.

*General Format of Autopsy Protocol:* The protocol is composed of
several parts, which are described in the following order:

I. **Patient Data: (Note additional line in the case of a submitted
autopsy)**

Autopsy Number: A88-00

Patient's Name: Doe, James

Unit Number: 10-10-10-1

Age: 100

Sex: Male

Race: White

Institute: National Institute on Aging

Branch: PLEASE BE VERY SPECIFIC

Type of Autopsy: Full

Date and hour died: 01-01-90 at 1:00 p.m.

Death at NIH: YES or NO, at (where?)

Date and hour autopsy performed: 01-01-90 at 2:00 p.m.\
(Date autopsy submitted: )

Prosector: James Doe, M.D.\
(Use NIH resident's name for submitted cases)

Autopsy assistant: John Doe

II. **Clinical Diagnoses:**

This section should include a concise, problem-oriented list of patient
diagnoses available to the clinicians at the time of death. Relevant
surgical and cytopathological case numbers should be included.

1\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
etc.

III\. **Final Anatomic Diagnoses:**\
The *final pathologic diagnoses,* both gross and microscopic, should
comprise an outline of the patient's disease processes presented in the
pathogenetic and chronological sequence of development based on both
clinical and autopsy findings. The pathologic diagnoses include every
major abnormality encountered in the case. The aim is to show at a
glance the pathogenesis of the disease processes, with the most
important events first. Use proper outline format with the most
important disease process as the first item. Significant negative
diagnoses (such as No residual tumor) should also be included.

IV\. **Cause of Death:**\
Write one sentence including the immediate cause and the chief
underlying cause of death.\
This should be a brief, one-sentence summary that includes the most
important Immediate Cause of Death and the Underlying (Proximate) Cause
of Death. The Underlying Cause of Death should be etiologically
specific. The term "cardiorespiratory failure" should not be used as
this is a universal description of death and provides no useful
information.\
Example: Aspergillus bronchopneumonia secondary to widely disseminated
malignant lymphoma.

V. **Clinical Summary:**\
This is a brief review of the clinical course and should include onset
of disease, duration, significant therapy, and mode of death. One-half
page will often suffice.

VI\. **Gross Description:**

a.  Use present tense.

> b\. Follow required order and follow the format of the attached
> example of a gross description.

EXTERNAL DESCRIPTION:

PRIMARY INCISION:

NECK ORGANS:

PERITONEAL CAVITY:

PLEURAL CAVITIES:

HEART:

LUNGS:

SPLEEN:

PANCREAS:

GASTROINTESTINAL TRACT:

LIVER:

BILIARY TRACT:

ADRENALS:

KIDNEYS:

URETERS:

BLADDER:

GENITALIA:

LYMPH NODES:

VEINS:

ARTERIES:

BONE:

PERIPHERAL NERVOUS SYSTEM:

SKULL:

PITUITARY:

BRAIN:

c\. Be objective and complete but brief when describing lesions.

d\. Do not use diagnostic terms

> e\. Weigh accurately with scales and measure with a ruler. Do not
> guess or approximate.
>
> f\. Keep the whole heart and brain from any case where the cause of
> death is not obvious at autopsy until the cause *is* determined.
>
> g\. Photographs are important.

VII\. **Microscopic Description:**

a\. Use present tense.

b\. Label slides with pencil according to organ and/or site.

c\. Write a short summary of the most significant changes found by
microscopy using the same organ order as in the gross description. This
should not be a list of diagnoses. Tumors should be briefly but
graphically described: pattern, size of cells, size of nuclei, nuclear
structure, and whether differentiated structures are formed. When tumor
cells are found in more than one organ, the common features of tumor
cells should be summarized at the beginning of the microscopic
description. Do not describe normal organs.

d\. Describe the results of special stains, immunohistochemistry and
ultrastructural studies.

e\. Include the names of consultants.

VIII\. **Clinicopathological Correlation (CPC):**

This is not a summary but an interpretation of the pathological
findings. The CPC should begin with a paragraph that opens with a 1--2
sentence summary of the patient's clinical course. This should be
followed by a list of the important clinical questions raised prior to
or after the autopsy. The succeeding paragraphs should address each of
the clinical questions, from most to least important. The emphasis
should be on trying together all of the clinical, laboratory and
pathological data into a coherent whole. Unexpected findings should be
discussed with a comment on their clinical significance. The CPC should
close with a brief paragraph summarizing the discussion and giving the
cause of death.

IX\. **Microbiological Studies:**

a\. Review clinical record for a possible infectious process (especially
hepatitis B and HIV) before the autopsy is begun.

b\. Obtain heart blood culture routinely.

c\. Culture abscesses and purulent exudates and/or secretions and obtain
direct smears.

d\. Submit material from granulomatous lesions for culture for both
acid-fast organisms and fungi.

e\. Requisitions to bacteriology should not only be labeled with
patient\'s name and autopsy number but should also indicate the type of
lesion being sampled (i.e., enterocolitis, putrid empyema, meningitis,
pneumonia, etc.). Specimens should be transported to microbiology by
dieners.

f\. Tissue and/or aspirated fluids obtained aseptically usually prove of
much greater value than swabs in the isolation of fungi, mycobacteria,
and fastidious bacteria.

g\. When contamination of the specimen is suspected at the time of
collection, please indicate on the requisition whether you are
interested in recovering or ruling out a specific organism.

X. **Clinicopathologic Correlation:**

This will be short or long according to the individual case and is *not*
a summary but a comment regarding interesting, instructive, or puzzling
features of the case. This is your interpretation of the case.
References may be used to advantage, and should be cited in the
discussion.

XI\. **Code of Sections:**

This is an essential part of the autopsy report. Specifically designate
the site within each organ system, i.e., Lung, right upper lobe.

XII\. **Signatures:**

Be sure to date your signature.

Sign & Date:

James Doe, M.D. (Resident Pathologist)

JD:lir:0000 Date (Dictated) Date (Transcribed)

Sign & Date:

John Doe, M.D. (Attending Pathologist)

(Enter Date Submitted to Medical Records Department)

Sign & Date:

Jane Doe, M.D. (Attending Neuropathologist)

######