The autopsy lexicon: suggested headings for the autopsy report.

CONTEXT: Although standard autopsy texts and other publications discuss the general content of autopsy reports, and some provide examples of autopsy report formats, no publication to date has recommended specific headings for autopsy report organization. The College of American Pathologists Autopsy Committee decided it would be helpful to provide suggestions for autopsy report headings to foster more standardized autopsy reporting, to facilitate review of reports by third parties, and to facilitate searches of electronically stored autopsy reports.

OBJECTIVES: To create a model document (named the Autopsy Lexicon), which defines standard categories of information that are useful to include in autopsy reports; to offer specific wording for the headings of various sections of the report; and to explain the rationale for including the various items of information and headings.

PARTICIPANTS AND METHODS: The members of the Autopsy Committee of the College of American Pathologists prepared the document by reviewing various examples of autopsy report formats, identifying specific categories of information usually contained in such reports, and developing wording for various sections of the autopsy report that would contain specific information. A draft was submitted to 45 members (including 12 forensic pathologists) of the College of American Pathologists for review, comment, and reality testing. Reviewers included pathologists from both community and academic settings. Comments of reviewers were incorporated to the extent possible.

RESULTS: The Autopsy Lexicon was prepared and is a model document for autopsy pathologists who wish to define an autopsy template of headings for consistent organization of autopsy reports.

CONCLUSIONS: The Autopsy Lexicon is available to foster more uniform reporting of autopsy information, which may facilitate review of autopsy reports and retrieval of information from electronically stored autopsy reports.