Autopsy Protocol

AUTOPSY PROTOCOL, an official document compiled by a prosector or a person replacing them for every autopsy performed for research purposes within the walls of medical and clinical institutions. The autopsy protocol contains (in order): the current autopsy number, the date of the latter, the surname, name, and patronymic of the deceased, their age, profession, time of admission to the medical institution and day of death, and the clinical diagnosis. This is followed by an objective and accurate description of the anatomical findings, starting from the data of the external examination of the corpse, and then the data obtained from the examination of the cavities and various systems of the body. The description itself is conducted clearly and sufficiently fully, but at the same time concisely, without superfluous words (in a semi-telegraphic style). The order of recording the discovered data generally corresponds to the order of autopsy and examination of various parts of the body, which is best achieved when recording by dictation from the person performing the autopsy. The protocol can also be written after the autopsy, but necessarily on the day the latter is performed. When recording after the autopsy, it is recommended to conduct the description of the corresponding findings by body systems, so as, on the one hand, not to miss anything, and on the other hand, immediately to provide in the protocol sufficiently systematized material, which is especially important for research analysis and pedagogical purposes. With some experience, systematized recording (nervous system, endocrine organs, circulatory, digestive, respiratory, sexual, urinary systems, etc.) can also be carried out by dictation during the section. Each autopsy protocol ends with an anatomical diagnosis, representing a brief summary of what was discovered. The anatomical diagnosis is headed by the primary condition, which, in the opinion of the prosector, brought the patient to the hospital bed. This primary condition (appendicitis, stomach cancer, tubal pregnancy, etc.) is unfolded in the anatomical diagnosis according to the main stages of its course with an indication of complications and so-called causes of death (appendicitis, perforation of the appendix, fecal peritonitis; or: stomach cancer, metastases to the liver, cachexia; or: tubal pregnancy, rupture of the tube, acute hemorrhage into the abdominal cavity). The anatomical diagnosis should by no means be headed by complications or the cause of death (peritonitis, cachexia, hemorrhage in the given examples). Following the formulation of everything related to the primary condition, the anatomical diagnosis includes various other corresponding conditions of varying duration, for example, a patient with appendicitis could have a registered tuberculosis of the lung apex, a patient with stomach cancer could have arteriosclerosis, pulmonary emphysema, etc. In complex cases, a "conclusion" can be added to the protocol, in which instructions are given on the course of the process, the dependence of various changes on each other, and the cause of death. The main autopsy data are necessarily substantiated by histological examination of the corresponding objects, especially in cases of doubts regarding the correct interpretation of phenomena at the sectional table. The data of the histological examination, as well as bacteriological and serological data, are attached to the autopsy protocol. For greater objectivity, it is also desirable to attach numerical data relating to the weight of the organs (liver, brain, heart, spleen, kidney, etc.). No corrections or crossings out are allowed in the autopsy protocol; if the need for such arises during the course of additional studies, special reservations are made in the conclusion of the autopsy, up to fundamental changes in the "primary diagnosis or its construction." The anatomical diagnosis is transferred to the history of the deceased patient with the signature of the prosector. For the forensic medical autopsy protocol, see Forensic autopsy.