Synoptic reporting produces more consistent results more efficiently than traditional surgery reporting techniques such as dictation and transcription. It creates structured data about a medical event without the need for narrative transcription. This in turn improves efficiency and reduces the chances of errors creeping into the report. [1, 2, 3.] Electronic reporting can further enhance patient care through fast and clear communication between healthcare professionals.
And yet, despite its advantages, synoptic reporting continues to face resistance to widespread adoption. There are many reasons for this, but a key one is the lack of templates. Creating a refined template represents a significant investment of time and resources. However, the payoff is worth it.
Building a Better Template.
Whether you still rely on pen and paper reports, or have upgraded to an electronic clinical documentation program like Synoptec, you’ll need a report template that’s both informative and concise. To develop a truly exceptional synoptic report, you’ll have to follow six important principles.
- Be comprehensive.
- Keep it simple.
- Limit text entry.
- Review, refine, repeat.
- Use electronic forms.
- Think research reporting.
Remember that synoptic templates need to be useful for everyone involved. Take a look at the synoptic reporting templates on offer from the College of American Pathologists (CAP). In-depth and complete, they capture relevant data about every aspect of a medical event. When it comes to medical reporting, providing relevant information as possible is crucial. Great templates capture all the reportable data they can.
Keep it Simple.
Ensuring your synoptic report is comprehensive is important, but the great value of synoptic reporting is its efficiency and simplicity. Keeping your template as simple as possible will make it easier to navigate the report, and help other healthcare professionals find the information they need.
Allow text entry – but only for exceptions.
It’s impossible for a templated reporting system to cover every contingency that might be uncovered during a medical event, so don’t try. There will always be a need for some degree of text entry. What’s important to remember is that text entry can be a source of error if the wrong information is written down, or is illegible. If you’re not ready to commit to electronic reporting where legibility isn’t a concern, keep templates as text free as possible. For example, it may be easy to list common options followed by an “Other” field, but you should be listing out as many outcomes as possible. Use “Other” only when absolutely necessary.
Also, consider whether the information you’re recording is important, and if it will be of value to most clinicians. While any data point may eventually be useful, remember the 80/20 rule. Capture the information that you must (e.g. liability requirements) and then capture information that will be of value in 80% of cases. Making the effort to keeping your synoptic reports as simple and short as possible will go a long way to acceptance by colleagues.
Review, Refine, Repeat.
Great templates don’t just happen. You need to subject your templates to rigorous review from multiple perspectives. Of course, those who are going to be using a template the most should have the most input, but it’s always good to get different perspectives. New perspectives on your templates can spot oversights, and force you to defend your decisions so you’re not gathering irrelevant data. Rigorous peer-review is also critical to creating comprehensive and efficient synoptic templates. Remember that you don’t need a template to be perfect the first time. Just build it. You’ll be refining it multiple times before it’s ready anyways.
Use Electronic Forms When Possible.
The electronic format of synoptic reporting offers many important advantages over hard copy reporting. Not only can you template questions, but you can template answers as well. Electronic reporting features like validation and conditional branching help prevent errors by revealing or hiding information based on past input. By adopting an electronic synoptic reporting program, users are forced to abide by built in business rules that help prevent incorrect data entry.
Think Research Reporting
Good synoptic report templates don’t rely on any single body of knowledge. They require subject matter expertise, an understanding of how data needs to be structured, and more. They can also represent a significant investment of resources, particularly if multiple reports are being developed.
What’s more, if you’re implementing an electronic reporting solution, it’s good to have some computer-savvy skills on the team. Experienced IT professionals can structure data for effective reporting and analysis. After all, one of the great benefits of electronic synoptic reporting is its ability to capture data. By bringing in a third party provider like Synoptec, your templates will have both the short term benefit of accurate, efficient reporting, and the long term benefit of properly recording data for study.
- McLeod RS, Kirsh R. What impact has the introduction of synoptic reporting for rectal cancer had on reporting outcomes for specialist gastrointestinal and nongastrointestinal pathologists? Archives of Pathology & Lab Medicine 2011;135(11):1471–5.
- Maniarf RL, Hochman DJ, et al. Documentation of quality of care data for colon cancer surgery: comparison of synoptic and dictated operative reports. Annals of Surgical Oncology 2014;21(11):3592–7
- Donahoe L, Bennett S, et al. Completeness of dictated operative reports in breast cancer–the case for synoptic reporting. Journal of Surgical Oncology 2012;106(1):79–83.