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Forensic pathology

Forensic autopsy report

General


Reviewer: Terrill L. Tops, M.D. (see Reviewers page)
Revised: 3 February 2013, last major update January 2013
Copyright: (c) 2003-2013, PathologyOutlines.com, Inc.

General
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● Completing a forensic autopsy report is an art in itself
● Everything, including the decedent's demographics, circumstances of death, external examination, clothing/personal effects, medical intervention, radiographic imaging, evidence of injury, internal examination, microscopic examination, specific organ system pathology consultation, final autopsy diagnosis, and opinion sections should complement one another in a cohesive manner
● No two autopsy reports are the same; keep an open-mind for each case
● If using a template, take care to make the appropriate changes to suit each case
● Cause of death (COD) is usually straightforward, but the manner of death (MOD) and mechanism of death tend to be more challenging

Differences from non-forensic autopsies
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● Forensic autopsies emphasize identification of deceased, time of death, proper handling of evidence, recognition of injuries and pathological conditions that may be relevant to the court case
● For homicide court cases, an autopsy report is only one piece of the pie
● Law enforcement investigators, attorneys, forensic science experts (e.g. trace evidence, fingerprints) and other expert witnesses will fill in the rest
● Depending on the jurisdiction, the cover page of a forensic autopsy report includes: demographics of the decedent, circumstances of death, identification, cause of death, and manner of death

Undetermined cases
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● Having an autopsy report with an undetermined cause and undetermined manner of death ("Undetermined/Undetermined") is very rare - only if all evidence at autopsy is inconclusive
● Frequency of undetermined cases: not more than 1-2% of all autopsy cases done by a forensic pathologist in one year

High profile cases
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● Conduct "VIP" / high profile cases as if you would routinely perform like any other case to avoid unnecessary mistakes
● Depending on the case, high profile or difficult autopsies should be checked by another forensic pathologist for accuracy
● FP should be board certified in at least anatomic and forensic pathology for competency measures

Demographics of the decedent
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● Decedent: person who died (a legal term)
● Include full name, autopsy number, social security number, age, date of birth, date of death, date of autopsy performed, place of death, and date of autopsy report completed

Circumstances of death
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● Events that occurred prior to the person's death, such as: when last seen alive, prior hospitalizations, and pertinent positive/negative evidence to support COD/MOD

Identification
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● Antemortem/postmortem fingerprint, dental, radiographs, or DNA comparison is objective evidence, and is added to evidence from pictures, driver license or other unique identifiers (e.g. tattoos or amputations)

Cause of death
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● Drowning, gunshot wound to the chest, acute myocardial infarction, multidrug toxicity (overdose), undetermined, etc.

Manner of Death
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● Accident, homicide, natural, suicide, or undetermined

End of Forensic pathology > Forensic autopsy report > General


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