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I wanted to know if there are any good descriptions in the literature on how to write a good epicrisis for an autopsy report. I really appreciate your input.
Advice for epicrisis in Autopsy
- Thread starter Playmate2002
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I am a boarded forensic pathologist. Post fellowship I did some forensics in the Navy from 1986-1988 and was an associate M.E. in Florida from 88-90. I had learned , or had adopted from many sources that I had read ( i think Alan Moritz was one of my inspirtations) that I really should not write much, if any, of a summary. I let the autopsy speak for itself. My summary would generally consist of a paragraph that read " The cause of death was a penetrating gun-shot to the head. The manner of death was suicide." There were a number of other forensic pathologists who adhered to this style. i believe Russ Fischer and Werner Spitz also did.
Any kind of a more verbose summary just let an attorney question you more.
hospital autopsies in an academic setting are a different critter, but never forget they can become forensic when the lawyers get hold. that is why when i was a teaching staff in a residency i discouraged a big summary---Cause , manner, and if desesired, mechanism of death.
I would encourage you to read "classical mistakes in medico-legal autopsies" by Moritz which was delivered to the ASCP upon his receipt of an award in the early 50's. It is an invaluable primer in the do's and don't's of medico-legal autopsies. You can probably pull it up on Google
Any kind of a more verbose summary just let an attorney question you more.
hospital autopsies in an academic setting are a different critter, but never forget they can become forensic when the lawyers get hold. that is why when i was a teaching staff in a residency i discouraged a big summary---Cause , manner, and if desesired, mechanism of death.
I would encourage you to read "classical mistakes in medico-legal autopsies" by Moritz which was delivered to the ASCP upon his receipt of an award in the early 50's. It is an invaluable primer in the do's and don't's of medico-legal autopsies. You can probably pull it up on Google
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I've done 42 autopsies thus far. 8 more to go.
My epicrisis generally goes like this:
-Brief history, dont go into details.
-Summarize significant gross and microscopic findings pertaining to cause of death.
-Summarize incidental findings.
-Immediate cause of death is from..
-Underlying cause of death is due to ...
My epicrisis generally goes like this:
-Brief history, dont go into details.
-Summarize significant gross and microscopic findings pertaining to cause of death.
-Summarize incidental findings.
-Immediate cause of death is from..
-Underlying cause of death is due to ...
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I don't recall ever hearing the term "epicrisis" before. Maybe I didn't study forensics well enough?
In my residency, our autopsy director was somewhat paranoid of legal issues (but a good teacher and a nice guy), so we did no summary, essentially no clinical history, not even a cause/manner of death. We listed all of the findings by organ system and then had a more detailed gross and micro below that. Shocking method to many residents from other institutions, but it seemed to work for us. Plus, it was MUCH easier than a more detailed write up. Our director's reasoning was similar to that mentioned by mikesheree: "Why make yourself more vulnerable legally by speculating or by including history from the chart (which is full of mistakes and errors)?" I have to say that his point makes some sense, in my opinion.
In my residency, our autopsy director was somewhat paranoid of legal issues (but a good teacher and a nice guy), so we did no summary, essentially no clinical history, not even a cause/manner of death. We listed all of the findings by organ system and then had a more detailed gross and micro below that. Shocking method to many residents from other institutions, but it seemed to work for us. Plus, it was MUCH easier than a more detailed write up. Our director's reasoning was similar to that mentioned by mikesheree: "Why make yourself more vulnerable legally by speculating or by including history from the chart (which is full of mistakes and errors)?" I have to say that his point makes some sense, in my opinion.
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epicrisis is an old school 19th century medical term. It is not just limited to autopsy summary but was once used to mean a summation of any event leading to one being put in the hospital or clinic.
This is very interesting; at my program we are *strongly* encouraged to go verbose in the clinical summary and in the final summary of the results for hospital cases. One of our autopsy pathologists likes if we fully explain the pathophysiology of the various ailments, with an eye toward making it readable for a non-medical person (likely the decedent's family). Our reports are consequently very long (8-10 single spaced pages, typically).
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argghhh...i hated doing that in residency. As alluded to in other posts, I was a bit shocked when I started in private practice over a year ago to hear that we didn't do an "epicrisis" or go into great detail about cause of death. We simply (thoroughly) report out the gross and microscopic findings. Admittedly, this can be somewhat confusing for the lay person reading the report, but on the flip side since having done 5-10 autopsies in the past year, on a couple of occasions I've sat down with the family to try to explain the findings in plain English (and done so happily), without necessarily stating point blank (and especially not in writing) the cause of death.
There are simply too many other clinical factors and pieces of info that we are not provided with to confidently and accurately state the cause of death in every case. An ideal "autopsy" report would involve path, rads, surgeon, clinical team etc. signing it it out collaboratively, which obviously is an impossible notion.
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All these different notions have their places. In the forensic world, generally speaking, both my training and my experience lends me to agree that less is usually better.
The autopsy report should consist of your anatomic findings. And that's really all, with the exception of the cause/manner opinion in some circumstances (ME's generally include this, and most pathologists who either also complete death certificates or advise coroners in completing death certificates seem to do so; non-forensic reports are another beast). But that doesn't preclude a "comment" or "opinion" section, laboratory results section, or a "clinical summary" or similar section (in the forensic setting this is usually usurped by an investigative summary written by a forensic investigator or similar non-pathologist).
In residency we did have a "clinical information" section in our autopsy reports, which consisted of a heavily consolidated version of a discharge summary in one or two short paragraphs. In residency we also had a "clinico-pathologic correlation" section at the end consisting of a summary of findings and why, taken as a whole, the cause of death conclusion was what it was. In forensic fellowship we had an "opinion" section, which was used somewhat variably by the supervising medical examiners -- some were paranoid about trying to anticipate and answer every possible lawyer-question and consequently tended to be verbose, while others did little more than re-write the bullet-point anatomic findings in a few short sentences. In retrospect, the opinion section helps me remember what I was thinking -- and in reviewing other people's cases, understanding why they concluded what they did -- but yes, a good lawyer may be able to let you paint yourself into a corner using them. Currently I very rarely add a "comment" section, usually reserved for undetermined cases, consisting of one or two sentences briefly explaining why it was undetermined.
I do think that in the training setting there is utility to writing a clinical information section and a clinico-pathologic correlation section, but you have to understand any autopsy (just like any medical record) could end up in court. So, in writing them, I would avoid being absolutist, avoid speculation, and feel free to reference relevant conclusions.
I don't have a good link to examples. My clinical information sections generally went something like: A 333 year old white male presented to ThisHospital's ER July 4, 2052 with shortness of breath and was admitted. His medical history was significant for coronary artery disease status-post CABG in 2044, chronic obstructive pulmonary disease on home O2 since 2048, deep venous thromboses, and nanobot nidus in the left lung following occupational exposure. His hospital course included magnet therapy, leech therapy, and hypothermia treatments. On July 7th, 2052 at 2330 hours he was found deceased on the bathroom floor.
But, everybody does it differently, and your bosses will likely have their own preferences.
As for all the different departmental specialists getting together to come to a conclusion about a patient, I always thought that was what morbidity & mortality conferences were for. Unfortunately they mostly seem to be within a department. We were rarely asked to comment on the autopsy findings, even preliminarily, at the M&M's which usually took place within a week of death (so usually before residency hospital autopsies were complete) -- which seemed to rather defeat the purpose. In the uncommon cases where the cause of death was complicated or unusual, I usually made/make a number of phone calls to those other specialists. Nevertheless, offering an opinion on the anatomic cause of death is still well within the training of an anatomic pathologist.
The autopsy report should consist of your anatomic findings. And that's really all, with the exception of the cause/manner opinion in some circumstances (ME's generally include this, and most pathologists who either also complete death certificates or advise coroners in completing death certificates seem to do so; non-forensic reports are another beast). But that doesn't preclude a "comment" or "opinion" section, laboratory results section, or a "clinical summary" or similar section (in the forensic setting this is usually usurped by an investigative summary written by a forensic investigator or similar non-pathologist).
In residency we did have a "clinical information" section in our autopsy reports, which consisted of a heavily consolidated version of a discharge summary in one or two short paragraphs. In residency we also had a "clinico-pathologic correlation" section at the end consisting of a summary of findings and why, taken as a whole, the cause of death conclusion was what it was. In forensic fellowship we had an "opinion" section, which was used somewhat variably by the supervising medical examiners -- some were paranoid about trying to anticipate and answer every possible lawyer-question and consequently tended to be verbose, while others did little more than re-write the bullet-point anatomic findings in a few short sentences. In retrospect, the opinion section helps me remember what I was thinking -- and in reviewing other people's cases, understanding why they concluded what they did -- but yes, a good lawyer may be able to let you paint yourself into a corner using them. Currently I very rarely add a "comment" section, usually reserved for undetermined cases, consisting of one or two sentences briefly explaining why it was undetermined.
I do think that in the training setting there is utility to writing a clinical information section and a clinico-pathologic correlation section, but you have to understand any autopsy (just like any medical record) could end up in court. So, in writing them, I would avoid being absolutist, avoid speculation, and feel free to reference relevant conclusions.
I don't have a good link to examples. My clinical information sections generally went something like: A 333 year old white male presented to ThisHospital's ER July 4, 2052 with shortness of breath and was admitted. His medical history was significant for coronary artery disease status-post CABG in 2044, chronic obstructive pulmonary disease on home O2 since 2048, deep venous thromboses, and nanobot nidus in the left lung following occupational exposure. His hospital course included magnet therapy, leech therapy, and hypothermia treatments. On July 7th, 2052 at 2330 hours he was found deceased on the bathroom floor.
But, everybody does it differently, and your bosses will likely have their own preferences.
As for all the different departmental specialists getting together to come to a conclusion about a patient, I always thought that was what morbidity & mortality conferences were for. Unfortunately they mostly seem to be within a department. We were rarely asked to comment on the autopsy findings, even preliminarily, at the M&M's which usually took place within a week of death (so usually before residency hospital autopsies were complete) -- which seemed to rather defeat the purpose. In the uncommon cases where the cause of death was complicated or unusual, I usually made/make a number of phone calls to those other specialists. Nevertheless, offering an opinion on the anatomic cause of death is still well within the training of an anatomic pathologist.
