Accuracy in pathology reporting and interpretation is vital to patient care, risk management and physician compliance. Clinical skill, no matter how insightful, is diminished by weak reporting practices.
Accuracy in pathology reporting and interpretation is vital to patient care, risk management and physician compliance. Clinical skill, no matter how insightful, is diminished by weak reporting practices. Structured practices for pathology reporting and particularly use of template (synoptic) formats, have been demonstrated to improve reporting quality [1, 2]. Pathologists are fortunate in that a comprehensive library of peer reviewed templates is provided by the College of American Pathologists in the form of the CAP Cancer Checklists. Some examples of final reports based on these templates appear below.
What is Synoptic Reporting?
Synoptic reporting is electronic medical reporting through entry of data into discrete fields. Structured synoptic reporting uses templates to guide clinician entry of relevant data and ensures complete, consistent results. Because clinicians can complete reports directly, report completion is less time consuming than narrative styles requiring transcription. A clinician may still enter narrative comments to supplement synoptic values if required.
Examples of Pathology Synoptic Reports
The best synoptic templates are peer-reviewed and use standards based on existing guidelines set by CAP and the American Society of Clinical Oncology. The templates produce reports such as the following:
In the respective synoptic report example, the pathologist indicates a patient’s relevant clinical history at the beginning of the report.
In the “Specimen” section, it is simple to see the type of procedure performed, information about the lymph node sampling and the site of the primary tumor.
The “Tumor” section is independent of the “Specimen” section to eliminate confusion. Within this section, a provider indicates the tumor type and its histological site. In a sub-section, the provider grades the tumor using the World Health Organization’s Grading System, as well as a relevant two-tiered grading system.
The “Extent” section allows the pathologist to enter information about the tumor, such as:
- Ovarian surface involvement
- The submission of other organs
The report also has separate sections for accessory findings, special studies and the tumor’s stage.
The hysterectomy-related synoptic report example is similar to the salpingo-oophorectomy example. Instead of listing a procedure as an element in the “Specimen” section, the pathologist lists “Procedure” as a sub-section in respective area.
In the “Tumor” section, the provider indicates a histologic type and the Federation of Gynecology and Obstetrics (FIGO) grade.
The “Extent” section offers information that’s specific to the myometrial invasion. It also discusses the involvement of the cervix and right ovary, and the presence of peritoneal ascetic fluid.
In the “Stage” section, the reader finds information regarding the primary tumor, specific sites, and distant metastasis and their locations.
In addition to creating reports about major procedures, a pathologist may use a synoptic format to create a report about a specimen. In the sample biopsy report, it is simple to learn about the type of procedure performed in the “Specimen” section.
The report’s “Tumor” is relatively short, and the provider identifies the histologic type and grade. The grade includes information about the appearance of the nuclei and its size.
This synoptic reporting example demonstrates how an institution can modify a template and group related items. It also shows how a provider may control the type of information that a specific role, facility or service provider sees to maintain compliance with privacy laws.
The synoptic format helps improve consistency while preventing errors and omissions in a medical institution’s pathology reports. In addition to simplifying the reporting process, this format can help a pathologist and a care team improve upon patient management procedures.