Building on the strengths of the College of American Pathologists (CAP) Cancer Protocols, synoptic reporting is a best practice for electronic medical documentation. The CAP clinical templates have set new standards for pathology reporting consistency. Now, new technology is further raising the bar across medical disciplines, improving pathology, surgery and radiology reporting.

What is Synoptic Reporting?

Synoptic reporting is a clinical documentation method that uses structured checklists to help clinicians produce more complete, consistent and valuable medical reports. Electronic synoptic reporting uses coded-value templates to quickly capture interoperable data in discrete fields.

Synoptic reports are faster to produce and easier to interpret. Because of their consistency and the ease of their distribution, electronic synoptic reports can be compiled and searched for quality assurance and clinical research.

Smart synoptic software streamlines HIPAA-compliant reporting with responsive clinical templates that prompt for clarifying details while hiding irrelevant fields. Moreover, clinicians can customize these templates—setting default data fields, configuring immediate error checking, and determining how smart branching templates respond.

Synoptic Reporting Benefits

Synoptic reporting produces better reports. Electronic synoptic reports prevent medical record errors, streamline clinician workflows, and improve the quality of patient care.

Synoptic reporting is a best practice because it empowers care teams to:

• Create consistent reports
• Increase report completeness
• Increase report readability
• Reduce medical record errors
• Improve turnaround times
• Eliminate transcription costs
• Streamline report distribution
• Measure and evaluate medical outcomes
• Plan long-term across multi-disciplinary teams
• Perform quality assurance and clinical research

Evidence of Effectiveness

Clinical research continually finds that the synoptic format results in more consistently complete reports, especially when compared to dictation or narrative text [1–7].

Not only are synoptic reports more likely to contain all of the information required for clinical decision making, synoptic reports also present this data in a format that is easier to interpret [8–12].

Electronic synoptic reporting is faster, resulting in more accessible data on medical outcomes [13–15].

1. Edhemovic I, Temple WJ, de Gara CJ, Stuart GC. The computer synoptic operative report–a leap forward in the science of surgery. Annals of Surgical Oncology. 2004;11(10):941–7.
2. 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.
3. Maniarf RL, Hochman DJ, Wirtzfeld DA, McKay AM, Yaffe CS, Yip B, Silverman R, Park J. 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
4. Branston LK, Greening S, Newcombe RG, Daoud R, Abraham JM, Wood F, Dallimore NS, Steward J, Rogers C, Williams GT. 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
5. Karim RZ, van den Berg KS, Colman MH, McCarthy SW, Thompson JF, Scolyer RA. The advantage of using synoptic pathology report format for cutaneous melanoma. Histopathology. 2008 Jan; 52(2):130–8.
   
6. Cross SS, Freeley KM, Angel CA. The effects of four interventions on the informational content of histopathology reports of resected colorectal carcinomas. Journal of Clinical Pathology. 1988 Jun;51(6):481–2.
7. Donahoe L, Bennett S, Temple W, Hilchie-Pye A, Dabbs K, Macintosh E, Porter G. Completeness of dictated operative reports in breast cancer–the case for synoptic reporting. Journal of Surgical Oncology. 2012;106(1):79–83.
8. Harvey A, Zhang H, Nixon J, Brown CJ. Comparison of data extraction from standardized versus traditional narrative operative reports for database-related research and quality control. Surgery. 2007 Jun;141(6)708–14.
9. Kang HP, Devine LJ, Piccoli AL, Seethala RR, Amin W, Parwani AV. Usefulness of a synoptic data tool for reporting of head and neck neoplasms based on the College of American Pathologists cancer checklists. American Journal of Clinical Pathology. 2009 Oct;132(4):521–30. 
10. Beatti GC, mcAdam TK, Elliott S, Sloan JM, Irwin ST. Improvement in quality of colorectal cancer pathology reporting with a standardized proforma–a comparative study. Colorectal Disease. 2003 Nov;5(6):558–62.
    
11. Aumann K, Amann D, Gumpp V, Hauschke D, Kayser G, May AM, Wetterauer U, Werner M. Template-based synoptic reports improve the quality of pathology reports of prostatectomy specimens. Histopathology. 2012 Mar;60(4):634–44.
12. Lankshear S, Srigley J, McGowan T, Yurcan M, Sawka C. Standardized synoptic cancer pathology reports – so what and who cares? A population-based satisfaction survey of 970 pathologists, surgeons, and oncologists. Achive of Pathology & Laboratory Medicine. 2013 Nov;137(11):1599–602.
13. Murari M, Pandey R. A Synoptic Reporting System for Bone Marrow Aspiration and Core Biopsy Specimens. Archives of Pathology & Laboratory Medicine. 2006 Dec;130(12):1825–29.
14. Srigley J, Lankshear S, Brierley J, McGowan T, Divaris D, Yurcan M, Rossi R, Yardley T, King MJ, Ross J, Irish J, McLeod R, Sawka C. Closing the quality loop: facilitating improvement in oncology practice through timely access to clinical performance indicators. Journal of Oncology Practice 2013;9(5):e255-61.
15. Temple WJ, Francis WP, Tamano E, Dabbs K, Mack LA, Fields A; Cancer Surgery Alberta. Synoptic surgical reporting for breast cancer surgery: an innovation in knowledge translation. American Journal of Surgery 2010 Jun;199(6):770–5. 

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