Clinical Documentation Improvement: Why Care About Synoptic Reporting?

Synoptic reports provide a more complete view of a patient’s condition than is generally achieved with longer narrative formats.

Synoptic reports provide a more complete view of a patient’s condition than is generally achieved with longer narrative formats. In a July 2003 article for CAP Today, Keith Anderson, MD, explains that the synoptic format is “concise standardized reporting that includes all data needed for accurate staging, treatment, and prognosis.” Synoptic reports are computer-based worksheets that medical professionals use to enter and obtain information in a manner that is quicker and more accurate than free-text reports.

The Benefits of Synoptic Reporting

Synoptic Reports are More Complete

Synoptic reports apply comprehensive checklists that help prevent reporting errors. Doctor Mahul Amin, vice chair of the CAP Cancer Committee and director of surgical pathology at Emory University Hospital, stated in a June 2004 CAP Today article that the checklists in synoptic surgical reports “(have) all the essential information for diagnosis, prediction, prognosis, and subsequent management of the patient.”

In the same CAP Today article, Chair of the CAP Cancer Committee, doctor Carolyn C. Compton explained that the checklists help prevent reporting omissions, adding, “If there is an issue that is difficult or impossible to convey in a completely standardized format, you’re free to put as much text commentary at the end of the synoptic report as you want…”

Pathologists who have used both formats tend to prefer the synoptic style because resulting reports are more complete and the consistent grading system helps eliminate confusion, according to the November 2013 article “Standardized Synoptic Cancer Pathology Reports — So What and Who Cares?” in the Archives of Pathology & Laboratory Medicine. The study showed the results of a survey completed by Ontario physicians.  

Clinical Documentation Improvement: Fewer Dictation- and Transcription-Related Errors and Omissions

It’s common for dictated and transcribed reports to contain omissions, as L. Donahoe et al. observed in the study “Completeness of Dictated Operative Reports in Breast Cancer—The Case for Synoptic Reporting” published in the January 2012 Journal of Surgical Oncology.

In CAP Today, Compton pointed out that the reduced reporting errors in synoptic formats help pathologists and their support staff save time because they do not have “to field phone calls because information is missing, and pull the slides for the pathologist, who has to read them again and issue an amended report that has to be typed by someone.”

Synoptic Reports are Simpler to Read and Understand

Just as a synoptic report is simpler to produce than free-text reporting systems, they are also easier to understand. In a 2002 CAP Today article, doctor M. Elizabeth Hammon, the Department of Pathology chair at LDS Hospital in Utah pointed out that the verbiage of traditional reports may bury critical information: “If you can read something as a bulleted list, you’re much more likely to get to that kernel of information more quickly than if you have to read an entire report.”

Faster Report Completion

Because the synoptic format doesn’t require narration or dictation, you are able to complete reports faster. In the 2002 CAP Today article, doctor David Frishberg, chief of pathology at Sinai Hospital of Baltimore, asserted, “I don’t think patient reports are really designed to be creative exercises. They’re designed to convey information…”

Useful Training Tool for Pathology Residents

Time available to train residents is always extremely tight. Synoptic reporting templates are a good training tool that focus residents on the key information they need to gather. Amin explained, “…Rather than trying to remember which is the essential one for a particular malignancy, they can actually focus their efforts on learning how to apply the checklist parameters rather than which parameters to include in their report. Thus, checklists actually help streamline the education process…”

The synoptic format has helped streamline the pathology reporting process for the computer-savvy and tech-hesitant alike. In addition to offering the flexibility that pathologists seek, the synoptic format produces high-quality reports that help elevate the standard of care offered to patients.