Pathology Synoptic Reporting Example and Definition

Pathology Synoptic Reporting Definition

pathologist-preparing-slide-for-synoptic-reportSynoptic reporting is the use of structured checklists to produce standardized clinical documentation. For pathologists, this usually means using the College of American Pathologists (CAP) Cancer Protocols and electronic Cancer Checklists.

Synoptic (structured) clinical templates ensure that pathologists are always prompted to report on the data that is critical for clinical decision making.

Synoptic reporting software digitizes this process, reducing reporting time and simplifying report distribution. Pathologists can produce consistently complete reports, using configurable templates, underpinned by interoperable codes such as SNOMED CT® and ICD-10.

Pathology Synoptic Report Example

The following pathology report example is based on the CAP template for Kidney Nephrectomy.

pathology synoptic report example synoptec

In the image above, all of the text was automatically filled in by selecting simple options from drop-down menus and radio buttons. Some systems include the option to add free text to clarify complex cases, but most reporting tasks can be more easily accomplished without typing, and with minimal mouse clicks.

Why Use Synoptic Reporting for Pathology?

Clinical research continually finds that synoptic reporting results in more complete pathology reports than dictation or narrative text [1–4]. Not only are synoptic reports more likely to contain all of data required for clinical decision making, the format of synoptic reports also makes it easier for fellow clinicians to find and interpret this necessary data [5].

Moreover, synoptic report data is more easily aggregated for both internal quality assurance and population-level cancer research. And HL7-compliant software ensures that your pathology reports can easily interface with existing systems—both within your lab and across your care network.

Implementing Synoptic Pathology Reporting

There are many forms of pathology reporting software. Some only work within specific EHRs, whereas others are widely interoperable. Some only run on desktop PCs, whereas others run on multiple platforms including mobile devices.

Most pathology reporting systems support the use of CAP Cancer Protocols. But only some make it easy for pathologists to configure CAP templates—without custom development from computer programmers. Some software requires your lab to have extensive IT infrastructure, whereas others can run in the cloud, enabling your team to access advanced infrastructure at a reduced expense.

  1. 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.
  2. Pignol JP, et al. Accuracy and completeness of pathology reporting–impact on partial breast irradiation eligibility. Clinical Oncology. (Royal College of Radiology) 2012 Apr;24(3):177–82.
  3. Branston LK, Greening S, Newcombe RG et al. The implementation of guidelines and computerised forms improves the completeness of cancer pathology reporting. The CROPS project: a randomised controlled trial in pathology. European Journal of Cancer. 2002;38(6):764–72.
  4. Karim RZ et al. The advantage of using synoptic pathology report format for cutaneous melanoma. Histopathology. 2008 Jan;52(2);130–8.
  5. Murari M, Pandey R. A synoptic reporting system for bone marrow aspiration and core biopsy specimens. Archives of Pathology & Labratory Medicine 2006;130(12):1825–9.