Post by Admin on Sept 30, 2021 11:47:53 GMT
San Carlo Memorial Clinic Autospy form to be sent and attached to Death certificate and all other municipal bodies when applicable. I.E Police, Fire, courts etc.....
Dr performing Autopsy:_____________________________
Date:_______________________________________________
CAUSE OF DEATH (See instructions and examples)
PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
IMMEDIATE CAUSE (Final
disease or condition ---------> a._____________________________________________________________________________________________________________
resulting in death) Due to (or as a consequence of):
Sequentially list conditions, b._____________________________________________________________________________________________________________
if any, leading to the cause Due to (or as a consequence of):
listed on line a. Enter the
UNDERLYING CAUSE c._____________________________________________________________________________________________________________
(disease or injury that Due to (or as a consequence of):
initiated the events resulting
in death) LAST d._____________________________________________________________________________________________________________
Approximate
interval:
Onset to death
_____________
_____________
_____________
_____________
PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I
DID TOBACCO USE CONTRIBUTE
TO DEATH?
□ Yes □ Probably
□ No □ Unknown
IF FEMALE:
□ Not pregnant within past year
□ Pregnant at time of death
□ Not pregnant, but pregnant within 42 days of death
□ Not pregnant, but pregnant 43 days to 1 year before death
□ Unknown if pregnant within the past year
MANNER OF DEATH
□ Natural □ Homicide
□ Accident □ Pending Investigation
□ Suicide □ Could not be determined
DATE OF INJURY
(Mo/Day/Yr) (Spell Month)
TIME OF INJURY
PLACE OF INJURY (e.g., Decedent’s home; construction site; restaurant; wooded area)
INJURY AT WORK?
□ Yes □ No
LOCATION OF INJURY: :
Street & Number: Apartment No.: Zip Code:
DESCRIBE HOW INJURY OCCURRED:
IF TRANSPORTATION INJURY, SPECIFY:
□ Driver/Operator
□ Passenger
□ Pedestrian
□ Other (Specify)
CERTIFIER (Check only one):
□ Certifying physician-To the best of my knowledge, death occurred due to the cause(s) and manner stated.
□ Pronouncing & Certifying physician-To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated.
□ Medical Examiner/Coroner-On the basis of examination, and/or investigation, in my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner stated.
Signature of certifier:_____________________________________________________
To Be Completed By: MEDICAL CERTIFIER
TITLE OF CERTIFIER
LICENSE NUMBER
DATE CERTIFIED (Mo/Day/Yr)
FOR REGISTRAR ONLY- DATE FILED (Mo/Day/Yr)
school completed at the time of death.
□ 8th grade or less
□ 9th - 12th grade; no diploma
□ High school graduate or GED completed
□ Some college credit, but no degree
□ Associate degree (e.g., AA, AS)
□ Bachelor’s degree (e.g., BA, AB, BS)
□ Master’s degree (e.g., MA, MS, MEng,
MEd, MSW, MBA)
□ Doctorate (e.g., PhD, EdD) or
Professional degree (e.g., MD, DDS,
DVM, LLB, JD)
(See Physicians’ Handbook or Medical Examiner/Coroner Handbook on Death Registration for instructions on all items)
ITEMS ON WHEN DEATH OCCURRED
CHANGES TO CAUSE OF DEATH
ITEM 1 - MANNER OF DEATH
IMMEDIATE CAUSE (Final
disease or condition ---------> a. Rupture of myocardium __________________________________________________________________________________
resulting in death) Due to (or as a consequence of):
Sequentially list conditions, b. Acute myocardial infarction_______________________________________________________________________________
if any, leading to the cause Due to (or as a consequence of):
listed on line a. Enter the
UNDERLYING CAUSE c. Coronary artery thrombosis_______________________________________________________________________________
(disease or injury that Due to (or as a consequence of):
initiated the events resulting
in death) LAST d. Atherosclerotic coronary artery disease__________________________________________________________________
Approximate interval:
Onset to death
Minutes
6 days
5 years
7 years
When processes such as the following are reported, additional information about the etiology should be reported:
Abscess
Abdominal hemorrhage
Adhesions
Adult respiratory distress syndrome
Acute myocardial infarction
Altered mental status
Anemia
Anoxia
Anoxic encephalopathy
Arrhythmia
Ascites
Aspiration
Atrial fibrillation
Bacteremia
Bedridden
Biliary obstruction
Bowel obstruction
Brain injury
Brain stem hern tion ia
Carcinogenesis
Carcinomatosis
Cardiac arrest
Cardiac dysrhythmia
Cardiomyopathy
Cardiopulmonary arrest
Cellulitis
Cerebral edema
Cerebrovascular accident
Cerebellar tonsillar herniation
Chronic bedridden state
Cirrhosis
Coagulopathy
Compression fracture
Congestive heart failure
Convulsions
Decubiti
Dehydration
Dementia (when not
otherw e specified) is
Diarrhea
Disseminated intra vascular
coagulopathy
Dysrhythmia
End-stage liver disease
End-stage renal disease
Epidural hematoma
Exsanguination
Failure to thrive
Fracture
Gangrene
Gastrointestinal hemorrhage
Heart failure
Hemothorax
Hepatic failure
Hepatitis
Hepatorenal syndrome
Hyperglycemia
Hyperkalemia
Hypovolemic shock
Hyponatremia
Hypotension
Immunosuppression
Increased intra cranial pressure
Intra cranial hemorrhage
Malnutrition
Metabolic encephalopathy
Multi-organ failure
Multi-system organ failure
Myocardial infarction
Necrotizing soft-tissue infection
Old age
Open (or closed) head injury
Paralysis
Pancytopenia
Perforated gallbladder
Peritonitis
Pleural effusions
Pneumonia
Pulmonary arrest
Pulmonary edema
Pulmonary embolism
Pulmonary insufficiency
Renal failure
Respiratory arrest
Seizures
Sepsis
Septic shock
Shock
Starvation
Subdural hematoma
Subarachnoid hemorrhage
Sudden death
Thrombocytopenia
Uncal herniation
Urinary tract infection
Ventricular fibrillation
Ventricular tachyc rdia a
Volume depletion
If the certifier is unable to determine the etiology of a process such as those shown above, the process must be qualified as being of an unknown, undetermined, probable, presumed, or unspecified etiology so it is clear
that a distinct etiology was not inadvertently or carelessly omitted.
The following conditions and types of death might seem to be specific or natural but when the medical history is examined further may be found to be complications of an injury or poisoning (possibly occurring long ago).
Such cases should be reported to the medical examiner/coroner.
Asphyxia
Bolus
Choking
Drug or alcohol verdose/drug or o
alcohol abuse
Epidural hematoma
Exsanguination
Fall
Fracture
Hip fracture
Hyperthermia
Hypothermia
Open reduction of fracture
Pulmonary emboli
Seizure disorder
Sepsis
Subarachnoid hemorrhage
Subdural hematoma
Surgery
Thermal bu
Dr performing Autopsy:_____________________________
Date:_______________________________________________
CAUSE OF DEATH (See instructions and examples)
PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
IMMEDIATE CAUSE (Final
disease or condition ---------> a._____________________________________________________________________________________________________________
resulting in death) Due to (or as a consequence of):
Sequentially list conditions, b._____________________________________________________________________________________________________________
if any, leading to the cause Due to (or as a consequence of):
listed on line a. Enter the
UNDERLYING CAUSE c._____________________________________________________________________________________________________________
(disease or injury that Due to (or as a consequence of):
initiated the events resulting
in death) LAST d._____________________________________________________________________________________________________________
Approximate
interval:
Onset to death
_____________
_____________
_____________
_____________
PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I
DID TOBACCO USE CONTRIBUTE
TO DEATH?
□ Yes □ Probably
□ No □ Unknown
IF FEMALE:
□ Not pregnant within past year
□ Pregnant at time of death
□ Not pregnant, but pregnant within 42 days of death
□ Not pregnant, but pregnant 43 days to 1 year before death
□ Unknown if pregnant within the past year
MANNER OF DEATH
□ Natural □ Homicide
□ Accident □ Pending Investigation
□ Suicide □ Could not be determined
DATE OF INJURY
(Mo/Day/Yr) (Spell Month)
TIME OF INJURY
PLACE OF INJURY (e.g., Decedent’s home; construction site; restaurant; wooded area)
INJURY AT WORK?
□ Yes □ No
LOCATION OF INJURY: :
Street & Number: Apartment No.: Zip Code:
DESCRIBE HOW INJURY OCCURRED:
IF TRANSPORTATION INJURY, SPECIFY:
□ Driver/Operator
□ Passenger
□ Pedestrian
□ Other (Specify)
CERTIFIER (Check only one):
□ Certifying physician-To the best of my knowledge, death occurred due to the cause(s) and manner stated.
□ Pronouncing & Certifying physician-To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated.
□ Medical Examiner/Coroner-On the basis of examination, and/or investigation, in my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner stated.
Signature of certifier:_____________________________________________________
To Be Completed By: MEDICAL CERTIFIER
TITLE OF CERTIFIER
LICENSE NUMBER
DATE CERTIFIED (Mo/Day/Yr)
FOR REGISTRAR ONLY- DATE FILED (Mo/Day/Yr)
school completed at the time of death.
□ 8th grade or less
□ 9th - 12th grade; no diploma
□ High school graduate or GED completed
□ Some college credit, but no degree
□ Associate degree (e.g., AA, AS)
□ Bachelor’s degree (e.g., BA, AB, BS)
□ Master’s degree (e.g., MA, MS, MEng,
MEd, MSW, MBA)
□ Doctorate (e.g., PhD, EdD) or
Professional degree (e.g., MD, DDS,
DVM, LLB, JD)
(See Physicians’ Handbook or Medical Examiner/Coroner Handbook on Death Registration for instructions on all items)
ITEMS ON WHEN DEATH OCCURRED
CHANGES TO CAUSE OF DEATH
ITEM 1 - MANNER OF DEATH
IMMEDIATE CAUSE (Final
disease or condition ---------> a. Rupture of myocardium __________________________________________________________________________________
resulting in death) Due to (or as a consequence of):
Sequentially list conditions, b. Acute myocardial infarction_______________________________________________________________________________
if any, leading to the cause Due to (or as a consequence of):
listed on line a. Enter the
UNDERLYING CAUSE c. Coronary artery thrombosis_______________________________________________________________________________
(disease or injury that Due to (or as a consequence of):
initiated the events resulting
in death) LAST d. Atherosclerotic coronary artery disease__________________________________________________________________
Approximate interval:
Onset to death
Minutes
6 days
5 years
7 years
When processes such as the following are reported, additional information about the etiology should be reported:
Abscess
Abdominal hemorrhage
Adhesions
Adult respiratory distress syndrome
Acute myocardial infarction
Altered mental status
Anemia
Anoxia
Anoxic encephalopathy
Arrhythmia
Ascites
Aspiration
Atrial fibrillation
Bacteremia
Bedridden
Biliary obstruction
Bowel obstruction
Brain injury
Brain stem hern tion ia
Carcinogenesis
Carcinomatosis
Cardiac arrest
Cardiac dysrhythmia
Cardiomyopathy
Cardiopulmonary arrest
Cellulitis
Cerebral edema
Cerebrovascular accident
Cerebellar tonsillar herniation
Chronic bedridden state
Cirrhosis
Coagulopathy
Compression fracture
Congestive heart failure
Convulsions
Decubiti
Dehydration
Dementia (when not
otherw e specified) is
Diarrhea
Disseminated intra vascular
coagulopathy
Dysrhythmia
End-stage liver disease
End-stage renal disease
Epidural hematoma
Exsanguination
Failure to thrive
Fracture
Gangrene
Gastrointestinal hemorrhage
Heart failure
Hemothorax
Hepatic failure
Hepatitis
Hepatorenal syndrome
Hyperglycemia
Hyperkalemia
Hypovolemic shock
Hyponatremia
Hypotension
Immunosuppression
Increased intra cranial pressure
Intra cranial hemorrhage
Malnutrition
Metabolic encephalopathy
Multi-organ failure
Multi-system organ failure
Myocardial infarction
Necrotizing soft-tissue infection
Old age
Open (or closed) head injury
Paralysis
Pancytopenia
Perforated gallbladder
Peritonitis
Pleural effusions
Pneumonia
Pulmonary arrest
Pulmonary edema
Pulmonary embolism
Pulmonary insufficiency
Renal failure
Respiratory arrest
Seizures
Sepsis
Septic shock
Shock
Starvation
Subdural hematoma
Subarachnoid hemorrhage
Sudden death
Thrombocytopenia
Uncal herniation
Urinary tract infection
Ventricular fibrillation
Ventricular tachyc rdia a
Volume depletion
If the certifier is unable to determine the etiology of a process such as those shown above, the process must be qualified as being of an unknown, undetermined, probable, presumed, or unspecified etiology so it is clear
that a distinct etiology was not inadvertently or carelessly omitted.
The following conditions and types of death might seem to be specific or natural but when the medical history is examined further may be found to be complications of an injury or poisoning (possibly occurring long ago).
Such cases should be reported to the medical examiner/coroner.
Asphyxia
Bolus
Choking
Drug or alcohol verdose/drug or o
alcohol abuse
Epidural hematoma
Exsanguination
Fall
Fracture
Hip fracture
Hyperthermia
Hypothermia
Open reduction of fracture
Pulmonary emboli
Seizure disorder
Sepsis
Subarachnoid hemorrhage
Subdural hematoma
Surgery
Thermal bu