CAP Adult Autopsy Reporting Protocol



Reporting Protocol for the Examination of Gross Autopsy of Adult DecedentsVersion: autopsy-adult-20.02Protocol Posting Date: February 2020Accreditation RequirementsThe use of this protocol is recommended for autopsy but is not required for accreditation purposes. This protocol may be used for the following procedures:ProcedureDescriptionAutopsyIncludes routine autopsy for adult decedentsThe following should NOT be reported using this protocol:ProcedureForensic autopsyPediatric autopsyAuthorsJody E. Hooper, MD*, Katie Flickinger, MS, PA (ASCP)CM*With guidance from the CAP Autopsy and Neuropathology Committees.* Denotes primary author. All other contributing authors are listed alphabetically.Summary of Changes20.02 – New autopsy reporting protocol Reporting TemplateNotes: This case summary may be useful for reporting autopsy findings but is not required for accreditation purposes. (NOTE A)PATIENT IDENTIFICATION AND CONSENT FOR AUTOPSYPatient name: ______________________Consent and patient ID reviewed byDr. ____________________Mr./Ms. ____________________Two unique patient identifiers reviewedPatient name: ____________________Date of birth: ____________________MRN: ____________________Other: _______________________ Type of autopsy___ Complete___ Brain only___ No head___ Chest only___ Abdomen only___ Other: ____________________Name of consenter: ____________________Relationship to the deceased: ____________________PRIOR POSTMORTEM PROCEDURES___ Organ Donation (select all that apply)___ Corneas___ Skin___ Bone and soft tissue (specify): _______________________ Organs (specify): _______________________ Other (specify): _______________________ Funerary Preparation (select all that apply)___ Eye caps___ Jaws wired or sewn closed___ Evidence of embalming (specify): _______________________ Other (specify): ____________________EXTERNAL APPEARANCE___ General ___ Well-developed___ Other (specify): _______________________ Age: ____________ Race___ Caucasian___ African American___ Hispanic___ Asian___ Other (specify): _______________________ Sex___ Male___ Female___ Other (specify): ____________________Body Weight (kilograms) _____kgBody Length (centimeters) _____cmBMI ______Note: use formula weight (kg)/ [height (m)]2___ Personal effect with or on the body___ No___ Yes (specify): _______________________ Toes / fingernails:___ Unremarkable___ Onychomycosis___ Koilonychia___ Splinter hemorrhages___ Cyanotic___ Other (specify): _______________________ Skin___ Unremarkable___ Other (specify): _______________________ Palpable lymph nodes___ No___ Yes___ Neck___ Axilla___ Groin ___ Other (specify): _______________________ Hair ___ None___ Balding___ Short___ Long___ Other (specify): _______________________ Hair color___ Black___ Brown___ Blond___ Grey___ Other (specify): _______________________ Eye color___ Brown___ Blue___ Hazel___ Green___ Other (specify): ____________________Pupil measurement- right (centimeters): _________ cmPupil measurement- left (centimeters): _________ cm___ Sclerae___ Anicteric___ Icteric___ Other (specify): _______________________ Ears___ Unremarkable___ Other (specify): _______________________ Nose___ Unremarkable___ Other (specify): _______________________ Oral cavity___ Good dentition___ Poor dentition___ Dentures___ No teeth___ Exam not performed due to rigor___ Other (specify): _______________________ External genitalia___ Normal male___ Normal female___ Other (specify): _______________________ Leg circumference 10 cm from medial malleolus___ Right (centimeters): ________ cm___ Left (centimeters): ________ cm___ Edema___ None___ Peripheral___ Generalized___ Other (specify): _______________________ Scars/ incisions___ None___ Present (specify): _______________________ Location (specify): ______________ Size (centimeters): ____ cm___ Evidence of therapy___ None___ Nasogastric tube___ PEG tube___ Endotracheal tube___ Foley catheter___ Other (specify): _______________________ Back___ Unremarkable___ Other (specify): ____________________INCISIONS AND BODY CAVITIES___ Incision___ Standard Y-shaped___ Biparietal___ Other (specify): _______________________ Organs in normal anatomic positions___ Yes___ No___ Other (specify): ____________________+ Panniculus (centimeters measured at thickest area): ________ cm___ Peritoneal fluid___ None___ Present (milliliters): __________ ml___ Serous___ Cloudy___ Serosanguinous___ Sanguinous___ Other (specify): _______________________ Peritoneal surfaces___ Smooth___ Adhesions___ Other (specify): _______________________ Right pleural cavity___ Smooth___ Adhesions___ Other (specify): _______________________ Right pleural fluid___ None___ Present (milliliters): __________ ml___ Serous___ Serosanguinous___ Sanguinous___ Other (specify): _______________________ Left pleural cavity___ Smooth___ Adhesions___ Other (specify): _______________________ Left pleural fluid___ None___ Present (milliliters): __________ ml___ Serous___ Serosanguinous___ Sanguinous___ Other (specify): ____________________CARDIOVASCULAR SYSTEM___ Heart weight___ (grams): _________ gNote: see reference table by patient weight___ Pericardium___ Intact___ Adhesions___ No adhesions___ Other (specify): _______________________ Pericardial fluid___ None___ Present (milliliters): __________ ml___ Serous___ Sanguinous___ Other (specify): ____________________+ ___ Epicardial fat+ ___ Minimal+ ___ Moderate+ ___ Large amount+ ___ Other (specify): _______________________ Epicardial surface___ Smooth___ Glistening___ Roughened___ Other (specify): _______________________ Coronary ostia___ Normally positioned___ Patent___ Other (specify): _______________________ Foramen ovale___ Closed___ Probe patent___ Other (specify): _______________________ Coronary arteries follow normal anatomic course___ Yes___ No___ Other (specify): _______________________ Coronary circulation___ Right dominant___ Left dominant___ Co- dominantAtherosclerosis___ Left anterior descending artery (LAD)___ None___ % stenosis: _____________ Eccentric___ Concentric___ Other (specify): _______________________ Left circumflex artery (LCX)___ None___ % stenosis: _____________ Eccentric___ Concentric___ Other (specify): _______________________ Right coronary artery (RCA)___ None___ % stenosis: _____________ Eccentric___ Concentric___ Other (specify): _______________________ Chamber dilation___ Yes___ No___ Other (specify): _______________________ Valve leaflets___ Thin/ delicate___ Other (specify): _______________________ Chordae tendinae___ Thin___ Other (specify): ____________________+ Valve circumferences+ Tricuspid (centimeters): _________ cm____ Abnormalities (specify): ____________________ Note: Reference range 10.0 – 12.5 cm+ Pulmonic (centimeters): _________ cm____ Abnormalities (specify): ____________________ Note: Reference range 7.0 – 9.0 cm+ Mitral (centimeters): _________ cm____ Abnormalities (specify): ____________________ Note: Reference range 8.0 – 10.5 cm+ Aortic (centimeters): _________ cm____ Abnormalities (specify): ____________________ Note: Reference range 6.0 – 7.5 cm___ Myocardium___ Firm___ Red-brown___ Other (specify): ________________________ Endocardium___ Smooth and thin___ Thickened___ Other (specify): ____________________Left ventricular free wall (centimeters): _________ cmNote: Reference range less than 1.5 cmRight ventricular free wall (centimeters): _________ cmNote: Reference range less than 0.5 cmSeptum (centimeters): _________ cmNote: Reference range less than 1.5 cm___ Pulmonary artery___ Appropriate caliber___ Normal configuration___ Contains embolus___ Other (specify): _______________________ Ascending aorta___ Appropriate caliber___ Normal configuration___ Other (specify): _______________________ Major arteries arising from aortic arch___ Normal configuration___ Patent___ Other (specify): _______________________ Thoracic aorta___ No atherosclerosis___ Mild atherosclerosis___ Moderate atherosclerosis___ Severe atherosclerosis___ Abdominal aorta___ No atherosclerosis___ Mild atherosclerosis___ Moderate atherosclerosis___ Severe atherosclerosis___ Venae cavae___ Patent___ Thin- walled___ Thrombi present___ Other (specify): ____________________RESPIRATORY SYSTEM___ Epiglottis, larynx, trachea___ No lesions___ Other (specify): ____________________Right lung weight (grams): _________ gNote: Reference range 360 – 570 gLeft lung weight (grams): _________ gNote: Reference range 325 – 480 g___ Fixation___ Fixed in distension___ Cut fresh___ Other (specify): _______________________ Right lung parenchyma___ Soft and pale red___ Other (specify): _______________________ Left lung parenchyma___ Soft and pale red___ Other (specify): _______________________ Bronchi___ Patent___ Other (specify): _______________________ Bronchial mucosa___ No lesions___ Other (specify): _______________________ Pulmonary arteries___ No atherosclerosis___ Atherosclerosis___ Pulmonary emboli (specify size and location)___ No pulmonary emboli___ Other (specify): ____________________DIGESTIVE SYSTEM+ ___ Tongue+ ___ Papillated+ ___ Smooth+ ___ Other (specify): _______________________ Esophagus___ Normal anatomic configuration___ Other (specify): _______________________ Esophageal mucosa___ White___ Intact___ Other (specify): _______________________ Squamocolumnar junction___ Sharply defined___ Indistinct___ Other (specify): _______________________ Stomach___ Empty___ Distended___ Contains partially digested food and liquids___ Other (specify): _______________________ Gastric mucosa___ Intact, rugated___ Other (specify): _______________________ Appendix___ Present___ Surgically absent___ Other (specify): _______________________ Small bowel___ Usual caliber___ Dilated___ Strictured___ Other (specify): _______________________ Small bowel serosa___ Tan pink shiny___ Adhesions___ Other (specify): ____________________Small bowel contents (specify): _______________________ Small bowel mucosa___ Tan___ No lesions___ Other (specify): _______________________ Large bowel___ Usual caliber___ Dilated ___ Stricture___ Other (specify): _______________________ Large bowel serosa ___ Tan pink shiny___ Adhesions___ Other (specify): ____________________Large bowel contents (specify): _______________________ Large bowel mucosa___ Tan ___ No lesions___ Polyps___ Diverticula___ Other (specify): ____________________+ ___ Superior mesenteric artery+ ___ No atherosclerosis+ ___ Degree of atherosclerosis (specify): ____________________+ ___ Other (specify): ____________________Liver weight (grams): __________ gNote: Reference range 1500 – 1800 g___ Liver capsule___ Smooth___ Glistening___ Intact___ Other (specify): _______________________ Liver parenchyma___ Slightly firm___ Firm___ Soft___ Maroon-brown___ Green tinged___ Yellow orange___ Rusty brown___ Mottled red___ Nodular___ No focal lesions___ Other (specify): _______________________ Gallbladder___ Present___ Surgically absent___ Other (specify): _______________________ Gallbladder wall___ Thin___ Fibrous___ Other (specify): _______________________ Gallbladder mucosa___ Velvety___ Green___ Other (specify): _______________________ Gallbladder contents___ Dark green mucoid bile___ No calculi___ Calculi___ Other (specify): _______________________ Extrahepatic biliary system___ Patent___ Other (specify): _______________________ Portal vein___ Patent___ Other (specify): _______________________ Hepatic arteries___ Patent___ Other (specify): _______________________ Hepatic veins___ Patent___ Other (specify): ____________________Pancreas dimensions (centimeters): ____ cm x ____ cm x ____ cmNote: Average 23.0 x 4.5 x 3.8 cm___ Pancreatic parenchyma___ Tan___ Firm and lobulated___ Autolyzed___ Other (specify): _______________________ Pancreatic duct___ Patent___ Not probe patent___ Other (specify): ____________________URINARY TRACTNote: Average combined kidney weight 230-440 gRight kidney weight (grams): __________ g___ Right kidney cortex___ Thickness (centimeters): ____ cm___ Smooth___ Granular___ Scarred___ Other (specify): _______________________ Right kidney parenchyma___ Red-brown___ Clearly demarcated corticomedullary junctions___ Ill-defined corticomedullary junctions___ Other (specify): _______________________ Right ureter___ Patent___ Not patent___ Dilated___ Not dilated___ Other (specify): ____________________Left kidney weight (grams): __________ g___ Left kidney cortex___ Thickness (centimeters): ____ cm___ Smooth___ Granular___ Scarred___ Other (specify): _______________________ Left kidney parenchyma___ Red-brown___ Clearly demarcated corticomedullary junctions___ Ill-defined corticomedullary junctions___ Other (specify): _______________________ Left ureter___ Patent___ Not patent___ Dilated___ Not dilated___ Other (specify): _______________________ Renal arteries___ Patent___ No atherosclerosis___ Mild atherosclerosis___ Moderate atherosclerosis___ Severe atherosclerosis___ Bladder___ Collapsed___ Volume of urine (milliliters): __________ ml___ Bladder mucosa___ Intact___ Other (specify): ____________________MALE REPRODUCTIVE TRACT (if appropriate)___ Prostate___ Normal size___ Enlarged___ Nodular___ Size (centimeters): ____ cm x ____ cm x ____ cm___ Other (specify): _______________________ Testes___ Normal size___ Enlarged___ Other (specify): _______________________ Testes cut surface___ Brown parenchyma___ Tubules string in normal manner___ Tubules do not string___ Other (specify): ____________________FEMALE REPRODUCTIVE TRACT (if appropriate)___ Uterus___ Present and appropriate size___ Present (comment): _______________________ Surgically absent___ Right Ovary ___ Size (centimeters): ____ cm x ____ cm x ____ cm___ Not identified___ Other (specify): _______________________ Left Ovary ___ Size (centimeters): ____ cm x ____ cm x ____ cm___ Not identified___ Other (specify): _______________________ Endometrium ___ Pale___ Red___ Other (specify): _______________________ Vagina___ Without lesions___ Other (specify): _______________________ Cervix___ Without lesions___ Other (specify): ____________________ENDOCRINE SYSTEMRight adrenal weight (grams): __________ gNote: Average weight 6 g (trimmed)Left adrenal weight (grams): __________ gNote: Average weight 6 g (trimmed)___ Adrenal parenchyma___ Uniform yellow cortices___ Good demarcation from the medullae___ Autolyzed___ Other (specify): _______________________ Thyroid___ Weight (grams): __________ g___ Symmetrical___ Red-brown___ Firm___ Nodular___ Other (specify): ____________________Note: Average weight 30 – 70 g___ Breast tissue contains small amount of white fibrous tissue within yellow fat___ Other (specify): ____________________LYMPHORETICULAR SYSTEMSpleen weight (grams): __________ gNote: Average weight 150 – 200 g unless over 80-years-old, then average 100 g___ Spleen capsule___ Smooth___ Intact___ Other (specify): _______________________ Spleen parenchyma___ Dark red___ Other (specify): _______________________ Bone marrow___ Dark red___ Hard___ Softer than usual___ Other (specify): _______________________ Lymph nodes___ Not enlarged___ Other (specify): _______________________ Thymus___ Not identified___ Age appropriate fatty replacement___ Present (weigh)___ OtherMUSCULOSKELETAL SYSTEM___ Diaphragm___ Intact___ Other (specify): _______________________ Skeletal muscles___ Red-brown and firm___ Appropriate mass for age/ gender___ Other (specify): _______________________Calvarium___ Intact___ Normal thickness___ Other (specify): _______________________ Vertebral column___ Normal curvature___ Kyphosis___ Scoliosis___ Other (specify): _______________________ Ribs___ Fractures (specify): _______________________ No fractures___ Other (specify): _______________________ Vertebral bodies___ No fractures___ Other (specify): ____________________CENTRAL NERVOUS SYSTEMGross brain observations at time of autopsy. Post-fixation brain cutting observations and tissue sampling will be considered in separate protocol (under development)Brain weight (grams): __________ gNote: Average weight 1100 – 1600 g___ Dura___ No lesions___ Epidural hemorrhage___ Subdural hemorrhage___ Removal reveals no bony abnormalities___ Other (specify): _______________________ Leptomeninges___ No lesions___ Subarachnoid hemorrhage___ Opacity or discoloration___ Other (specify): _______________________ Cerebral hemispheres___ No lesions___ Asymmetric (specify):_____________________ Atrophy (specify: diffuse, focal, lobar): ______________________ Edema (specify: diffuse, focal): _____________________ Other (specify): _______________________ Base of brain___ No lesions___ Uncal herniation___ Circle of Willis___ Normal___ Atherosclerosis (specify location and severity): ____________________ Aneurysm (specify location and type): _______________* Note: If a ruptured aneurysm is suspected clinically and hemorrhage is present at the base of the brain, it is advisable to wash away the blood and conduct a thorough search for the aneurysm before fixation of the brain.___ Other (specify): _________________ Cerebellum___ No lesions___ Tonsillar herniation___ Other (specify): _______________________ Brainstem___ No lesions___ Other (specify): _______________________ Spinal cord___ Length (cm from cut superior to conus): ___________cm___ No lesions___ Other (specify): _______________________ Not submitted___ Pituitary___ No lesions___ Other (specify): ____________________+ EYES+ ___ Eyes+ ___ Submitted+ ___ Not submitted+ ___ Other (specify): ____________________AUTOPSY PROCEDURES AND ANCILLARY TESTING___ Approach to autopsy dissection___ Rokitansky___ Virchow___ Other (specify): _______________________ Special dissection___ None___ Other (specify): _______________________ Tissue retention___ Stock jar___ All organs (until signout)___ Other (specify): _______________________ Additional samples taken___ Blood (specify): _______________________ Vitreous___ Tissue (specify): _______________________ Other (specify): _______________________ Ancillary testing___ None___ Radiology (specify): _______________________ Blood cultures (specify): _______________________ Tissue cultures (specify): _______________________ Toxicology (specify): _______________________ Other (specify): ____________________Explanatory NotesA.IntroductionThe aim of this protocol is to improve the completeness, clarity, and portability of autopsy reporting, while being mindful of the wide range of practice settings in which the data in the report is generated and disseminated. Autopsy reporting has traditionally been entirely in prose, a methodology which complicates real time dictation in many cases, and which does not make data easily retrievable, particularly across institutions. The protocol is based upon input from past and present members of the CAP Autopsy Committee, CAP Neuropathology Committee, and input from Katie Flickinger, MS, PA(ASCP)CM as well as the references below.The construction of this protocol does allow for the insertion of sentences where desired and thus combines the best of templating and traditional description. It is recommended that it be used as a paper copy or electronic tool directly in the autopsy suite while a case is being completed, though its use can be adapted as needed at different centers and depending on the information technology environment. Portions of the template may also be used in limited autopsies. Though this template represents the Autopsy Committee’s recommendations for inclusion in an autopsy report, some sections with a plus sign “+” are considered more readily optional in practice and could be omitted.Not only will the template provide more easily reproducible and extractable data, it may be used as a guide for trainees and pathologists who may only perform a limited number of autopsies in their practice. The committee hopes this is a first step in providing a general framework for more standardized quality autopsy practice.The content of the protocol represents the consensus opinion of the CAP Autopsy Committee. It was ordered by organ system rather than order of the block dissection in recognition of variations in dissection practices across institutions as well as to create the most intelligible final report. Recognizing that the order of elements may be adjusted by users, it is the Committee’s recommendation that all elements be included in the Gross Description. Microscopic sampling can also be institution dependent, but the Committee recommends broad histologic evaluation for autopsies.ReferencesFyfe-Kirschner B and Miller DK. The future of autopsy reporting: data repository and research support. In: Hooper and Williamson, editors. Autopsy in the 21st Century: Best Practices and Future Ideas. Switzerland: Springer;2019. 39-56.Wittekind C, Habeck JO, Gradistanac T. Proposals for standardization of autopsy reports. Pathologe 2014;35:182-190. R. The autopsy lexicon: suggested headings for autopsy reports. In: Collins K, editor. Autopsy Performance and Reporting. 3rd ed. Chicago: CAP Press;2017. 377-382. ................
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