So You Need to Write an Autopsy

Photo is of my parents' Japanese Maple tree. It's red and kind of like blood vessels if you squint. Photo by Kate Ota 2019

From murder mysteries to space operas, an autopsy can appear in all sorts of genres. Either a scene or a paper copy of the report can help clarify the cause of death for the characters invested in the outcome. Most people have never read or performed an autopsy and because of their legal and highly personal information, it’s hard to find reliable examples online. I’ve read dozens of autopsy reports as part of my day job. Here’s what you need to know about what an autopsy report contains.
 

Types of Examiners
Between different districts, the formatting of the autopsy report will vary, so don’t get stuck there. It’s the content that matters. Who performs an autopsy will also be different, there are Medical Examiners (ME) and there are coroners. You’ll need to research where your story is set (if it’s the real world) to learn who runs things. These offices may also have other employees who help the Chief ME or Lead Coroner, these employees may have titles such as Investigator.

Autopsies may also be performed by pathologists at the hospital, but this is generally outside of the legal realm. This occurs when either the hospital wants to see what they did wrong, prove they didn’t do something wrong when someone dies in surgery, or if the family pays for an autopsy after the ME/coroner declines. (Side note: private autopsies requested by the family can be crazy expensive!)
 

Types of Exams
In my experience, an ME/coroner also has two different types of post-mortem examinations. A view is done usually when cause of death is fairly clear, like a hanging or car accident trauma. An autopsy is more in-depth in detail and includes internal and external exam information. Usually this is for cases that may become court cases, like a potential homicide.
 

Content
An autopsy report will always include: who performed/was present for the exam, the decedent’s name, age/DOB, physical description, overview, cause of death. This is all written in the clearest phrasing possible, and with scientific terms only (example: clavicle instead of collar bone.)

The physical description includes hair and eye color, beard, mustache, circumcised (these last three are yes, no, or N/A), scars (surgical and non-surgical), tattoos, condition of skin/teeth/nails, weight, and if the person appears their age.

The overview will include things like signs of trauma, signs of medical intervention, and any medical information the autopsy uncovered, even if it’s not the cause of death. These incidental findings can include mild heart disease, nodules or cysts on organs, lung disease like asthma, etc.

Cause of death is very specific and technical, since this is a legal document. Be sure to research medical terminology to ensure the report states what your plot requires. If your autopsy report needs to say, essentially, “we don’t know why this person randomly died,” call it acute coronary insufficiency. This means the heart gave up all of a sudden.

An autopsy (rather than a view) will also include detailed descriptions of each major organ (including their weights) and descriptions of any microscopic slides made for the investigation. Slides are only taken from areas relevant to the suspected cause of death. Often this is done to determine if a medical condition contributed to death, such as cardiomyopathy or a pulmonary embolism.

Finally, in either homicides, suicides, or anything involving a motor vehicle, the odds are high the investigator will perform a toxicology screen. Generally, this will screen for alcohol, major illegal drugs, cannabinoids (legal or illegal), and forms of these drugs left after the body breaks them down. Other drugs or substances may be screened for if signs of their presence were at the scene of death, like an empty bottle of antidepressants or rat poison. Tox reports screen blood, urine, vitreous fluid (from the eye), and sometimes other fluids, like bile. They’re also stored for later screening if necessary.
 

Common Medical Terms

• Anterior: front of the body (as a person would appear while standing and facing you) which includes the palms and tops of feet (example: stab wounds to the anterior torso)
• Posterior: back of the body, which includes the back of the hands and underside of feet (example: bruising on posterior ribs)
• Medial: toward the midline of the body (example: a scar medial to the right shoulder)
• Lateral: away from the midline of the body (example: a mole lateral to the left patella)
• Superior: above (example: a freckle superior to the right eyebrow)
• Inferior: below (example: a gun shot wound entrance inferior to the left pectorals)
• Renal: refers to kidneys
• Gastric: refers to stomach
• Ocular: refers to the eyes/eye sockets
• Cardiac/coronary: refers to heart
• Pulmonary: refers to lungs
• Acute: a problem that is short term or new (example: acute coronary insufficiency)
• Chronic: a problem that has been or will be long term (example: chronic obstructive pulmonary disease or COPD)

 

Examples of Cause of Death Phrasing

• Gun shot wound(s) to [name of body part]
• Acute coronary insufficiency (basically their heart stopped working)
• Myocardial infarction (heart attack, which has more specific symptoms than acute coronary insufficiency)
• Combined [names of drugs] overdose (this would come with a separate toxicology report)
• Acute [name of drug] toxicity (this would come with a separate toxicology report)
• Hanging (the report would list the category of death being suicide, accident, homicide, etc.)
• Drowning (this may have an added note, such as "myocardial infarction contributing," if the person had a heart attack to cause the drowning)
• Blunt force trauma to the [name of body part] (used to describe injuries from car/motorcycle/bicycle/falling accidents)
• Sharp force trauma to [name of body part] (used to describe injuries of stabbing/slicing incidents)

 

I hope you found this autopsy overview helpful for your writing. Have any questions? Need help rephrasing your project’s cause of death to sound more scientific? Let’s discuss in the comments!