There are several requirements pertaining to gross photography in CAP's anatomic pathology checklist regarding surgical pathology and autopsy service:7
- ANP.12200 “All surgical pathology reports include gross descriptions, information essential for diagnosis and patient care, and essential processing information.”
- Annotated drawings and photographs can be used as valuable tools for documenting gross findings and can be included in the gross description of the surgical pathology report when appropriate. However, these are not intended to replace the text gross description. A written procedure for the reporting of gross examination findings on the surgical pathology report can serve as evidence of compliance.
- ANP.30080 “Autopsy Quality Management Program”
- In the general autopsy section, which also applies to forensic autopsies performed in hospitals, the checklist calls for a written quality management program for autopsy services, including processes to review autopsy performance and the quality of reports. Records of quality monitoring must be available as evidence of compliance. All aspects of the case, including gross photographs, must be reviewed and evaluated for patient identification and history, gross description, histologic sampling and staining quality, diagnosis, clinicopathologic correlation, special studies, and turnaround time.
- ANP.32550 “Photographic equipment is available, convenient, and functional.”
- The essential equipment should be available for demonstration to CAP inspectors.
- ANP.33380 “Photograph/Digital Image Labeling and Storage”
- The checklist requires photos and/or digital images to be labeled and stored in an appropriate manner. There must also be a system to prevent loss (e.g., an electronic storage system to back up data). The identifying label must be placed in a location that does not obscure the identifying features of the decedent. The record system must allow for the photographs to be easily retrieved.
- ANP.36075 “Photographs”
- The checklist details the types of photographs that should be taken during a forensic autopsy. This requirement is intended to remind people of the items to be addressed when taking photographs in a medical legal case to have as complete a photographic record as possible.
- ANP.36100 “Autopsy Notes and Photographs”
- The checklist requires written notes and photographs that would make it possible to reconstruct the autopsy report in the event dictations are lost or damaged.
7. Anatomic Pathology Checklist. (2023). College of American Pathologists.
