Institute of Tissue Medicine and Pathology, University of Bern, Bern, Switzerland.
Department of Laboratory Medicine and Pathology, Institute of Pathology, Lausanne University Hospital, University of Lausanne, Rue du Bugnon 25, 1011 Lausanne, Switzerland.
Virchows Arch. 2024 Jan;484(1):31-36. doi: 10.1007/s00428-023-03533-6. Epub 2023 Apr 5.
Synoptic reporting increases completeness and standardization of surgical pathology reports and thereby contributes to an increased quality of clinical cancer care. Nevertheless, its widespread practical implementation remains a challenge, which is in part related to the effort required for setup and maintenance of database structures. This prompted us to assess the effect of a simple template-based, database-free system for synoptic reporting on completeness of surgical pathology reports. For this purpose, we analyzed 200 synoptic reports (100 colon and 100 lung cancer resections each) for completeness as required by the pertinent College of American Pathologists (CAP) protocols and compared these to a control dataset of 200 narrative reports. Introduction of template-based synoptic reporting resulted in improved completeness (98% of mandatory data elements) as compared to narrative reports (77%). Narrative reports showed a high degree of completeness for data elements covered by previously existing dictation templates. In conclusion, template-based synoptic reporting without underlying database structure can be a useful transitory phase in the implementation of synoptic reporting. It can result in a similar degree of completeness as reported in the literature for database solutions and provides other benefits of synoptic reporting while facilitating its implementation.
概要报告提高了外科病理学报告的完整性和标准化程度，从而有助于提高临床癌症护理质量。然而，其广泛的实际实施仍然是一个挑战，部分原因是建立和维护数据库结构所需的工作量。这促使我们评估一种简单的基于模板、无数据库系统用于概要报告对外科病理学报告完整性的影响。为此，我们分析了 200 份概要报告（结肠癌和肺癌各 100 份），以评估其对相关美国病理学家学会 (CAP) 协议规定的完整性要求的符合程度，并将这些报告与 200 份叙述性报告的对照组进行了比较。与叙述性报告相比（77%），基于模板的概要报告在完整性方面有了显著提高（98%的强制性数据元素）。叙述性报告在涵盖先前存在的听写模板的数据元素方面具有很高的完整性。总之，在实施概要报告时，无底层数据库结构的基于模板的概要报告可以作为一个有用的过渡阶段。它可以实现与文献中报道的数据库解决方案相似的完整性程度，并提供概要报告的其他好处，同时促进其实施。
