Sec. 69-9.3. New York State Infant Autopsy Protocol

New York State department Of Health

 

Infant Autopsy Protocol

Decedent's name	Age	Sex	Race/Ethnicity
Local accession number	Date of birth	Date/time of death	Date of autopsy
Pathologist		County
1) FINAL CAUSE AND MANNER OF DEATH

2) STUDIES
Routine Studies	Normal	Abnormal	Not Done	Findings
Photographs	□	□	□
Full-body X-Rays	□	□	□
Toxicology	□	□	□
Histopathology	□	□	□
Neuropathology	□	□	□
Metabolic Screening	□	□	□
Blood/Tissue for future studies	□	□	□
Studies, as indicated	Normal	Abnormal	Not Done	Findings
Viterous samples for glucose	□	□	□
Microbiology/Virology	□	□	□
Genetic Studies	□	□	□
Electrolytes	□	□	□
HIV Testing	□	□	□

COMMENTS:

 

 

 

 

 

_____ DOH-4278 (9/30) p1

3) CLINICAL SUMMARY
Maternal Age:
Birth Weight (in grams):			Gestational Age:
Pregnancy Complications:
Medical History	YES	NO	NOT AVAILABLE	COMMENTS
Maternal Smoking	□	□	□
Maternal Alcohol Use	□	□	□
Maternal Drug Use	□	□	□
Sibling with SIDS	□	□	□
Other Relative with SIDS	□	□	□
Other Infant or Child Deaths	□	□	□

Sleeping Position (put to sleep):	□ Supine	□ Prone	□ Side	□ Unknown
Co-Sleeping:	□ Yes	□ No	□ Unknown
Describe sleep habits and bedding, if known:
COMMENTS:
4) DEATH SCENE INVESTIGATION
	□ Indicated		If indicated, state date:
	□ Not indicated		If not indicated, state reason:
COMMENTS:
PATHOLOGIST		Date Form Completed
DOH-4278 (9/03) p2

Autopsy Format

• Final Diagnoses

• Final Cause and Manner of Death

• External Examination

• Portmortem Changes

• Scars / Other Distinguishing Characteristics

• Clothing

• Weights and Measures

• General Appearance / Development

• Injuries (External and Internal)

• Therapeutic Procedures

• Resuscitation Evidence

• External Integument

• Internal Examination Head Neck Body Cavities Cardiovascular System Respiratory System Liver, Gallbladder and Pancreas Hemolymphatic System Genitourinary System Endocrine System Digestive System Musculoskeletal System

• Post-Mortem Studies Full body X-rays Histopathology Toxicology Metabolic Screen Neuropathology Cultures Blood/Tissue retained for future studies Other

_____ DOH-4278 (9/03) p3