Importance of Synoptic Reporting In Clinical Documentation
Clinical documentation is very significant with regard to appropriate patient care. Typically, a medical transcription company provides transcription service that help streamline medical documentation for healthcare providers. When physicians are required to complete the documentation on their own, they tend to adopt shortcut methods to save time and may end up creating incomplete or unreliable medical records.To make clinical documentation more efficient, medical practices use synoptic reporting. Synoptic reporting is a clinical documentation method that uses a structured checklist to help physicians produce complete, consistent and valuable medical reports. It is easier to produce output and easier to interpret.Due to their consistency and ease of distribution,electronic synoptic reportis considered a valuable option. Smart synoptic software enables HIPAA-compliant reporting with responsive clinical templates that prompt for clarifying details while hiding irrelevant fields. It also allows physicians to customize these templates.
Advantages of Synoptic reporting
- A complete report: Synoptic reports are comprehensive checkliststhat help avoid medical 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 synoptic report’s checklist consist of all essential data required for diagnosis, prediction, prognosis and subsequent management of patients. In the same article, Dr Carolyn C. Compton, Chair of the CAP Cancer Committee, explained that the checklists help to prevent reporting omissions and if there is any issue that is difficult or impossible to convey in standard format, you are free to put as much text commentary at the end of the report. Pathologists for instance, prefer synoptic style because it results in a more complete and consistent report with grading system that helps to avoid unnecessary confusion.
- Better clinical documentation: Dictated and transcribed reports may have omissions butreporting errors are minimal in a synoptic report. This results in better clinical documentation, lesser confusion or hassles for treating physicians, and better quality patient care.
- Easier to read and understand: Synoptic reports can be easily produced when compared to free text reporting system and so they are easier to understand. According to M. Elizabeth Hammon, the Department of Pathology chair at LDS Hospital in Utah, if you are able to read something as bullet points then you are very much likely to understand the essence of the information more quickly than reading the whole report.
- Quick completion: Synoptic reports do not require any narration or dictation and so you will be able to complete medical reports faster. This is very important, given that the primary objective of patient reports is to convey information. Traditional medical reports are descriptive and information is likely to get lost.
In synoptic reporting, the clinician is guided through a template designed to ensure complete data entry. Important fields can be marked as mandatory, and this would trigger a notification to the clinician in case important data is omitted. Synoptic reporting templates are a good training tool that encourages residents to focus on the key information they need to gather. This saves valuable time and residents can concentrate on learning how to apply the checklist parametersrather than which parameters to include in their report. The synoptic format has helped streamline the medical documentation process for the computer-savvy and tech-hesitant alike. It produces high-quality reports that help elevate the standard of care offered to patients. However, the continuing relevance of a medical transcription service cannot be ignored because physicians hard-pressed for time continue to depend on these services.