When using any type of clinical documentation method, there is always a concern about errors within patient reports.
When using any type of clinical documentation method, there is always a concern about errors within patient reports. Even though the CAP templates provide an excellent structure for pathology reports it is still possible, typically by way of user error, to create a report where answers are inconsistent throughout the document.
Synoptic reporting has become known for its ease of use, as well as for its ability to assist Pathologists and other practitioners in eliminating errors. The question is, how is it possible to avoid errors when the templates are being provided by CAP? In other words, can the templates sometimes be too rigid and static when a simple adjustment might remove the possibility of human error?
Let’s examine an example from CAP’s adrenal biopsy template for illustration…
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CAP Templates
The excellent structure of the CAP checklist provides a solid foundation for recognizing and eliminating errors in pathology reports.
However, it is still important to continue to check the accuracy of reports that are being created, and pathologists have had to consistently check for errors on patient oncology reports. This is time-consuming for everyone on the treatment team and potentially dangerous to the patient. That said, updated CAP templates are extremely valuable, which is why it may be beneficial to adjust the reporting experience.
One course of action could be to develop internal protocols that make it conspicuous to the user what fields apply to specific questions. Let’s take the Primary Tumor (pT) questions as an example. Only certain options should be available depending on the tumor size that is entered at the beginning of the report. A table could be created that could show which primary tumor fields should be completed depending on the tumor size.
| Adrenal Gland Tumor | Tumor Size <5cm | Tumor Size >5cm |
| CBD | O | O |
| pT0: No ev. of tumor | O | X |
| pT1: >5cm, no invasion | O | X |
| pT2: <5cm, no invasion | X | O |
| pT3: any size, loc. invasion | O | O |
| pT4: any size, adj. invasion | O | O |
X marking fields that do not apply. This table might be kept where the CAP checklists are accessible, perhaps even incorporated into the Word or PDF document.
One of the more notable features of some synoptic reporting software systems is that updated CAP cancer templates are populated into the system automatically. That means the days of researching the newest templates and regulations are long gone.
Branching Logic and Pathology Reporting Software
In synoptic reporting software, branching refers to a particular way certain data entry fields are enabled or eliminated in the CAP tumor templates based on previous data that is entered by the user. For example, perhaps you have a patient who has been diagnosed with a malignant tumor, and the template is prompting you to enter its size. More information is required about the tumor at other points in the template, and some of that information is repetitive. This is where a mistake due to human error is possible, and why there is such a demand for change in the way clinical documentation is performed.
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Note: When no value is entered all pT fields remain available for further clarification. See next figure for branching logic applied to the synoptic report.
When synoptic reporting software implements branching, once tumor size is entered into the template, any other options that would otherwise be available that do not support the entered numerical value are eliminated. This is really ideal, and it is the reason Pathologists prefer to work with these updated, automatic error-checking template systems.
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Note: branching logic automatically removes irrelevant fields in the Primary Tumor (pT) section once a value is added above in the Tumor Size field.
Increased Pathology Reporting Efficiency
In addition to providing you with advanced error checking technology, this method of reporting is an excellent way to increase your overall efficiency level. With the older reporting methods you have used in the past, reporting was tedious and time-consuming. However, technology has advanced to such a degree that you should be able to take full advantage of the new reporting methods with complete confidence that your work will be completed quickly as well as accurately.
Supportive of Multidisciplinary Teams
Fortunately, this error-checking technology is available for more than just adrenal Pathology templates. It actually ventures across multiple disciplines, which means that other Physicians will have the same type of clinical documentation experience. It is especially helpful in instances like this when multiple clinicians are working with the same patient’s medical record. Information is still easy to share, and simple to access for any member of the team who has Internet access, but the technology that is applied to the template helps to eliminate the errors that can sometimes result in those situations as well.
Synoptic reporting is a revolutionary clinical reporting method that incorporates the automation of CAP templates as a way of simplifying the documentation method for everyone on the treatment team. In reaching the goal of reducing the probability of errors, you will also be increasing the standard of care you are able to offer to your patients, which is exactly what you want to achieve.
