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Pre‐mortem information: Historical and clinical information are equally as important in the investigation as transcribing observations at the necropsy. Pre‐mortem information includes clinical signs, date of intake and onset of illness, location held in the shelter, and all treatments received. Especially in a shelter, this information is necessary to identify patterns of susceptibility to disease over time, whether geographical, age‐related, treatment‐associated, time of year, etc. This information is also essential to interpret the necropsy and histological lesions, and/or to compare future or past cases. Pre‐mortem and historical information can be written on a separate form or can be included on the necropsy form itself.

Necropsy results: There are several well‐organized necropsy templates available (see resources below) and a shelter should have copies of one of these on hand. Which directions, forms, and/or templates are used are not important; they are designed to remind the prosector (the person doing the dissection) to be methodical, thorough, and consistent. It is important to try to be as objective as possible in reporting observations; specifically, to describe abnormalities without presuming cause (without adding interpretation). For example, if the liver appears large, the organ should be weighed or, if there is no scale, describe how this interpretation was made: “The edges of the liver lobes were rounded and the caudal aspect of the liver extended to….” The features (shape, position, color, consistency) should also be noted if the liver is abnormal. In this same example, the objective gross diagnosis is “hepatomegaly,” or large liver. Knowing if a liver is too big or too small is useful, as the differential causes are entirely different, but the interpretation of organ size based on weight relies on its comparison (ratio) with the bodyweight of the animal.

If an organ or system was not examined, this should also be noted (e.g. if only the abdominal cavity and gastrointestinal system were examined and sampled, there should be a note on the report saying that organs within the thoracic cavity were NOT examined).