Appropriate, clear and concise clinical documentation methods are vital for every patient’s medical record. Excellent documentation results in the best possible care being administered, by the attending physician as well as any specialists who are attending to the patient’s case.
Appropriate, clear and concise clinical documentation methods are vital for every patient’s medical record. Excellent documentation results in the best possible care being administered, by the attending physician as well as any specialists who are attending to the patient’s case.
In the field of Pathology, clinical documentation is even more critical. Pathologists use patient records for more than diagnostic reasons. They also use it for recommending treatments, for researching treatment methods and improving medical outcomes. It should come as no surprise that The Joint Commission has issued new requirements for accreditation, which began on July 1, 2014. As of that date, every Pathology lab is required to use synoptic reporting in order to qualify.
Synoptic Reporting
As a Pathologist, you have undoubtedly been faced with countless hours of research that were made longer simply because the information you needed was not readily accessible to you. Traditional clinical documentation methods, or even methods that utilize basic electronic health records systems simply do not provide the searchability or standardized data that’s needed for adequate research. As a result, researching a particular type of cancer treatment or type of cancer can take months or even years. This is inefficient at best, and it does nothing for improving the level of care you’re able to offer to your patients.
Synoptic reporting systems offer a simple solution to this problem by using templates that are built in a way that requires that a streamlined set of terminology, measurements and other data points are used in reports. It also has required data fields that must be filled in when the report is filed. This is an excellent feature because it protects the physician and the patient against any missing data in medical records.
Highiighting the importance of synoptic reporting is this passage in the CoC report, Cancer Program Standards 2012, Ensuring Patient-Centered Care:
“The cancer committee should encourage its pathology
departments to adopt the synoptic format defined by
the CAP cancer committee for use in cancer-related
pathology reports. This definition is posted in the
CoC Best Practices Repository located on the Cancer
Programs page of the American College of Surgeons
website at www.facs.org/cancer/coc/bestpractices.html“
The College of American Pathologists
As you know, the College of American Pathologists (CAP) regularly issues updates regarding cancer protocols. Keeping track of these updates has been difficult in the past, not to mention time consuming. The Joint Commission recognizes how challenging this has been, yet they also recognize how important it is in order to continue to facilitate excellent treatment plans for cancer patients. Synoptic reporting offers a solution in that it provides automatic updates according to the most recent changes in CAP cancer protocols. There is no longer a need to manually track updates, and all research time is able to be dedicated to patient care and diagnostic responsibilities.
The Benefits of the New Pathology Lab Accreditation Requirements
While there are many reasons The Joint Commission has started requiring synoptic reporting for accreditation, they all fall under the heading of providing an improved level of care for patients. Synoptic reporting ensures that patient records are accurate, and it also ensures that they’re completed and available in a timely manner. Patient records that use one unified language offer Pathologists the tools they need to research variables quickly and precisely. This is an excellent way to improve medical outcomes over a much shorter period of time. While current cancer patients will certainly benefit from the change, it’s also important to note that future cancer diagnoses will benefit tremendously. That means that more appropriate treatments can be identified and started as well.
Fortunately, The Joint Commission’s new requirements can only benefit the field of Pathology. Synoptic reporting is not only more efficient, it’s also more cost-effective that traditional documentation methods. As a result, these new requirements offer a situation in which every participant stands to benefit tremendously. Patients will finally be able to utilize the level of care they really need, and Pathologists will be able to research appropriate improvements in care. While some benefits will be immediate, we should expect to experience more and more over time.