Synoptic reporting—structured, electronic entry of medical report data—offers many advantages for both clinicians and administrative staff. Here’s how the two processes compare in some key areas.
Efficiency of Medical Reporting
If your organization relies on the traditional free dictation and transcription method of reporting, you know that this system can result in significant delays. First, clinicians may postpone dictation of reports to complete several in one sitting. Then, the report goes into a transcription queue, and turnaround times may vary. Finally, if there are additions or corrections to the report, it must be returned for editing.
In contrast, synoptic reporting can be completed in one step, with the clinician entering data directly. Depending upon the approval process you choose, those reports may be available for sharing and distribution immediately upon completion. And, because synoptic report completion is relatively quick and easy and doesn’t require special equipment, many clinicians complete reports more promptly.
Thoroughness of Reports
Over the past several years, many studies have concluded that traditional dictation and transcription methods result in incomplete data. This lack of information can impact both individual patient care and the ability of researchers to access data necessary to improve outcomes in the field. Synoptic reporting, on the other hand, guides the clinician through a template designed to ensure complete data entry. And, fields can be marked as mandatory, triggering a notification to the clinician if important data is omitted.
A study published in the Journal of Surgical Oncology in July, 2012, concluded:
The dictated operative report for breast cancer surgery does not adequately capture important data. A synoptic reporting system, which requires documentation of important elements, is a potentially beneficial tool in breast cancer surgery.
That benefit is not purely speculative. In 2011, a study of reporting outcomes in rectal cancer cases, researchers concluded: “Completeness of reporting, irrespective of subspecialist interest, was dramatically increased by the use of a synoptic report.”
Ease of Access to Medical Data
Transcribed medical reports are managed in a variety of ways. Some may be printed and entered into hard copy files, while others are made part of electronic medical records. Unfortunately, even those stored electronically may be difficult to use for any purpose other than individual patient care.
Synoptic reporting, with its consistent fields and clear labeling of data, makes it easy for administrators and researchers to search, compile reports and otherwise assemble data in the manner necessary to improve outcomes for a particular condition or procedure in an individual facility or throughout the medical profession.
Synoptic reporting is quicker and easier for clinicians, eliminates a step that creates the risk of introduced errors, improves thoroughness and creates a more useful record for your organization and the medical profession as a whole.
Photo credit: Ian Monroe