The Autopsy (Necropsy; Postmortem) Report

The most important portion of the autopsy report as far as the abstractor is concerned is the section entitled "Final Diagnosis". It usually will describe the primary site, histologic type, and extension and metastases of the tumor based on a histopathologic examination of the tissues obtained after death. All of the major organs are examined unless, as sometimes happens, the autopsy is restricted to certain organs. All pertinent findings should be recorded.

Autopsy findings confirm the diagnosis of cancer made prior to death, if still present, and may determine the primary site of a tumor which may have been incorrectly diagnosed or unknown prior to death. The histologic findings described in the autopsy report relative to the primary site and cell type usually take precedence over those reported in prior pathology reports.

On occasion, the presence of cancer will be an incidental discovery at the time of the autopsy. When this occurs, the patient's history and physical examination findings should be reviewed to rule out a clinical diagnosis of cancer prior to death. In instances where the diagnosis of cancer was first made at autopsy, the cases are abstracted and identified as "diagnosed at autopsy". In such cases the date of diagnosis is the date of death.

The autopsy report for patients who died in your hospital should be included in the medical record. The autopsy protocols for those who die after discharge may be available from other hospitals or coroners' offices. Your Cancer Committee should decide whether to recommend that you attempt to obtain autopsy reports (and Death Certificates) for those patients who died elsewhere.

If the autopsy report is based on gross observation alone (no microscopic exam) this should be noted. However, as part of most autopsies, a histologic examination of tissue removed from the body will be performed routinely.

The following Practical Examples show both a typical and complete autopsy report. For each example, abstract what you think is pertinent and then compare with the suggested abstraction.