The report of a dissection is a document ; the dissecting veterinarian acts as an authority. Results may later be needed for a judicial argument, even if at the time of dissection this is not yet known to the examiner. Therefore, results of a dissection should always be noted in an adequate form and like any scientific report must be clearly divided into two parts:
 

1) a protocol of the dissection: the facts observed (data noted during dissection and and subsequent laboratory results) which, if a necropsy report is needed at court, are not subject to doubts as long as examination methods are adequate. the protocol must contain objective descriptions (for instance measurements instead of the terms "large" or "small", descriptions of abnormal findings, see below; normal findings are not described). Description should not be replaced by diagnostic terms which already include some subjective interpretation. The dissecting method should only be decribed when for some reason a method distinct from the normal ones is used.
For judicial use, the protocol must be signed by the examiner.

What should be noted in the protocol
Based on  Schoon (lecture manuscript), Wobeser, Spraker (1980), Rabinowitz et al. (2000) and Munson (2000)

A case number should be assigned; this number should be noted on all labels and records for samples
Time, place of dissection
Examiner, other persons present
Carcass found / sent by / owner of animal
Animal(s): Information about the genus, species, local names and other data of the animal examined as far as known.

Why is the animal considered to belong to the taxon? (Correctness of the taxonomic name of course depends on the state of taxonomic knowledge. Therefore, many museum specimens collected before development of actual taxonomy may be suspected to be mislabelled)

History of the case (collected prior to necropsy)

The gross necropsy findings, description of abnormalities found at necropsy
Any abnormality should be described by the following criteria:
       Location
       Number and distribution
       Colour
       Size
       Shape (when distinct from normal shape)
       Consistency and texture,
       Edges, surfaces (superficially and of cut surfaces and opened cavities)
       Abnormal presence of liquids
For example: "The liver contains multiple tan, firm nodules ranging from 1 to 3 cm in diameter that are distributed throughout all liver lobes. The nodules are gritty on cut surface."

Photos, microscopic slides, parasites etc. related to the case or animal
A list of bacterial, viral cultures / samples submitted for laboratory studies
Results of all ancillary tests (microbiology, toxicology etc.)

2) the diagnosis, which is a discussion of the facts with resulting conclusion and may at court be questioned and discussed. Diagnosis may include the following parts:

Pathological / anatomical diagnoses
Histopathological diagnoses
Results of other laboratory examinations of samples (for instance bacteriology, toxicology)
An epicrisis (final critical report about the development of a disease) or appraiser´s statement (legal advice) to answer a relevant question
A diagnosis may include information about quantity / intensity, quality,
  age (acute = sudden, severe change, sub-acute = less acute and severe, chronical = developing slowly),
  extent (for instance diffuse = spreading without clear borders), etiology = cause of the changes.

with certainty (~ 100%)
with  a probability close to certainty (~ 95%)
with high probability (~ 85%)
probably (~ 60-70%)
... is possible (~ 50%)
... is unlikely (~ 10%)
... is impossible (0%)
If no final evaluation of the findings is possible, the diagnosis may include statements like
... the most frequent cause of the observed change is ...
... the cause of the observed change may be ...

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In: Loris and potto conservation database: field methods  http://www.species.net/primates/loris.

Last amendment: 7 November 2002