The question is, how can you structure a pathology report in such a way that it can be beneficial for every person who is a part of the patient’s care team?
Efficiently summarizing the key points of the report may be the answer.
Providing CAP Template Data to All Team Members
First of all, it is imperative that medical reports contain all of the essential data regarding the patient’s care and diagnosis simply because reports are read by different readers. However, in order to maintain the readability of the report, there must be clearly-identified sections coupled with a clean layout. Formatting and excellent control over the formatting result in the data being easy to access for every member of the treatment team while allowing for the creation of an all-inclusive report. This is necessary for the pathology research team when they are working on medical outcome analysis.
[Related: How to Improve Clinical Documentation Processes]
Adding a Synoptic Report Summary Section
Although it is important to provide a complete report, not every member of the treatment team is going to require every piece of data within a patient report in order to provide care for the patient. Researchers require a more complete report than other members of the treatment team, such as oncologists and the patient’s primary care physician. The question then becomes, how can the CAP checklist serve both groups? The answer is in creating a summary section in the synoptic report.
A summary section pulls out the most critical elements from that patient’s report, providing every team member with easy access to the information they really need. The creation of the summary is simplified in synoptic reporting because the template provides the ability to check off key elements in the report that belong in the summary. In the finished report, the search function also allows for easy location of any summary information within the body of the report.
Including Narrative Comments
Although CAP templates provide an excellent foundation, they can be somewhat limiting when additional information is required by a Primary Care Physician, or when it becomes necessary to share additional data with other members of the team. For that reason, having the ability to include narrative comments within the CAP templates is an excellent feature of synoptic reporting. It also provides the opportunity for any additional questions to be asked, and those questions can easily be located and addressed directly within the patient’s report. That means this important data is not lost in the patient’s medical record, and any recommendations are easily and quickly implemented.
In synoptic reporting, the goal is twofold – to provide patients with an excellent standard of medical care, and to equip every member of the patient’s treatment team with the critical data and diagnostic information that is necessary to provide that excellent standard of care.
Example of a summary section of a synoptic pathology report.
By utilizing CAP templates in synoptic reporting, and making the necessary additions and adjustments, you will find that you are able to quickly and efficiently assess what your patients need as a part of their treatment plans. You will also find that your research capability is simplified as you seek to understand and improve patient medical outcomes.
