ABSTRACT

This chapter outlines the variety of types of documentation that can be used by the pathologist to inform the reader of the findings of the examination. Autopsy reports and statements should be produced promptly and should be available as soon as possible. Delays in producing autopsy reports render them of less use to clinicians, cause administrative difficulties for medicolegal authorities, can delay funerals and cause undue distress for relatives. Prior to discussion of the different types of document that can be generated, a short discussion concerning data storage, transmission and disclosure is required. Autopsy paperwork contains personal data that should be protected similarly to other forms of medical information. An excellent autopsy may be marred by the presentation of a poor report/statement. Conversely, an excellent report/statement may be generated from a substandard autopsy. The language of the autopsy report/statement should be that of the mother tongue of the country of practice, which for the UK is English.