Synoptic Reporting for Electronic Medical Documentation
Synoptic reporting is a template-based method for producing electronic medical documentation that is more timely, more accurate and more actionable than narrative or dictated medical reports. The benefits of synoptic reporting are well established in leading research journals.
For some medical disciplines, excellent synoptic template libraries are already established.
[Related: How to Design Clinical Templates]
For pathology, the College of American Pathologists (CAP) has been developing evidence-based clinical templates for over 20 years: the CAP Cancer Protocol Templates are peer reviewed and updated frequently. For a reasonable fee, the CAP templates can be downloaded as Word documents or integrated into your reporting software like Synoptec™, and you can be reporting according to best practices in minutes.
For radiology, the RSNA templates are an important resource. These templates have not yet had the years of refinement the CAP templates have gone through, and they are currently geared towards providing evidence-based structure to narrative reporting. But the RSNA templates are an excellent starting point for implementing synoptic reporting in diagnostic imaging.
Other clinicians have implemented synoptic reporting by developing their own synoptic templates, with the help of synoptic template software.
Developing Synoptic Templates
For 20 years, Softworks Group has helped our clinical partners implement synoptic reporting for electronic medical documentation. With the Synoptec™ synoptic reporting software, we equip care teams to design and configure clinical templates unique to their workflows.
Sophisticated clinical templates are often created by doctors and support staff for use in their internal programs. Sometimes, this is a single template designed to capture data from multiple clinics, such as the impressive Low-Dose CT reporting template created for lung cancer screening by Dr. Alain Tremblay in Calgary.
Other groups have created large template libraries to address a broad range of procedures. Cancer Surgery Alberta has used Softworks Group software to build operative reporting templates, covering procedures for breast, colorectal, gynecology, liver, and various other tumor groups. Cancer Surgery Alberta’s success using clinical templates has been documented in several leading medical journals [1–3].
The synoptic templates developed for an internal program are sometimes shared with other groups providing similar services. Synoptec™ makes this particularly easy to do using its built-in Template Store feature.
But for many clinicians, implementing synoptic reporting will require your team to develop synoptic templates that best suit your patients’ care pathways.
Best Practices for Developing Clinical Templates
In our 20 years of designing and implementing clinical templates, Softworks Group has learned several lessons about how to help our care team partners design synoptic templates:
- Set up a multidisciplinary design group to focus on how medical reports are used throughout the care team.
- Sketch out care pathway diagrams to help visualize how and when synoptic reports will support patient care.
- Collect data that supports clinical decision making. This ensures clinical templates collect necessary data, without leading to excessive reporting times.
- Develop multiple, smaller templates. This ensures that reports can be completed at or near the point of care, and reports can be quickly available to fellow clinicians.
Clinical Template Software
Each synoptic reporting implementation is unique. So it’s important to partner to pair evidence-based best practices with the requirements unique to your care team. And it’s important to choose synoptic reporting software that enables you to conveniently configure clinical templates and update them as best practices evolve.
- 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 Oct;11(10):941–7.
- Mack LA, Bathe OF, Hebert MA, Tamano E, Buie WD, Fields T, Temple WJ. Opening the black box of cancer surgery quality: WebSMR and the Alberta experience. Journal of Surgical Oncology. 2009 Jun 15;99(8):525–30.
- 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.