Evidence that Synoptic Reporting Improves Clinical Documentation

bigstock-Research-Blue-Marker-56818856The various types of medical transcription solutions have improved in quality over the years. However, which methods are getting the best results when it comes to clinical documentation improvement? There have been many studies completed on the effectiveness of synoptic reporting, and these studies indicate that this method has proven to be the most effective in many areas. Even so, many physicians have hesitated in making a change because they were unsure about just how beneficial synoptic reporting can be when it comes to overall patient care.

Perhaps you can relate, and you’ve been wondering if synoptic reporting would provide you with the tools you need to improve quality of care as well as the level of efficiency within your practice or facility. If so, we have compiled some statistics from recent studies that will offer you some additional information.

Complete Clinical Documentation

Complete surgical reports have been an issue for surgeons for years. A study published in the Journal of Surgical Oncology in a survey of one hundred consecutive breast cancer surgical reports, 84% of them were incomplete regarding their diagnostic details. As many as 60% of the reports were missing critical information such as the potential for breast conservation following surgery. This study concluded that a dictated report is not sufficient enough to capture the important data after these types of surgical procedures.

Similar findings are seen in reports from the studies of synoptic reporting in other surgical specialties as well. One such study involved collecting reports from rectal surgical resections that were performed from 1997-2008. Synoptic reporting for surgical outcomes was introduced to these physicians in the year 2001, and the study indicated that there was a dramatic increase in the completion levels of reports after that time. Other reports from comparable studies have shown that 31% to 51% of the reports that were included contained complete information when reports were dictated. However, when synoptic reporting was used, that percentage rose to 99%-100% This is a substantial increase, and it effectively demonstrates the effectiveness of synoptic reporting in the operating room.

Smart Synoptic Reporting

Synoptic reporting provides other benefits for surgeons and patients in addition to allowing for more complete reporting techniques. It also serves as a valuable educational tool for the surgeon because it provides reminders and alerts for all of the critical components of the patient’s treatment. Oncology experts agree that these reminders are an important part of the overall treatment plan. They also have found that by reminding surgeons of every step of a patient’s care plan—both historically and in the future—this knowledge provides surgeons with ability to improve patient outcomes.

Efficient Synoptic Reporting

Timeliness has always been a concern when it comes to determining the best clinical documentation solutions. For a study published in the The American Journal of Surgery, when 1,392 breast cancer procedure reports were compiled using synoptic reporting:

  • 91% of reports were finished within one hour
  • 97% of reports were finished within twenty-four hours
  • 52% of reports were finished within five minutes

When the study was completed, researchers found that 84% of these reports were in complete compliance with practice guidelines. As a result, 89% of surgeons adopted the synoptic reporting template for their reports, and 75% of them were satisfied with the results.

In conclusion, the research supports synoptic reporting for physicians, finding clinicians are satisfied with the level of information they are provided with as a result. Not only is the information relevant and complete, but it also aids them in all of the decision-making processes they encounter through every stage of a patient’s treatment.