Standardization of the surgical pathology report: formats, templates, and synoptic reports.
The most important routine vehicle for communication in surgical pathology is the specimen report. Although accuracy, clarity and thoroughness are the main goals, significant variability in format and content exists. In an effort to make reports more consistent, several mechanisms are useful and amenable for use in a computerized environment. These include templates, checklists, and tabular data reporting in the form of so-called synoptic reports. Such mechanisms are designed to ensure that critical information can be obtained consistently and easily from the report regardless of the institution of origin. Standardization is most easily extended to specific types of specimens, such as those resulting from mastectomies or colectomies with malignant neoplasms. The ultimate goal of the mechanisms discussed herein is to attain uniformity and consistency of included data found to be relevant to clinical management of patients.
Leslie
K O
KO
Department of Pathology, University of Vermont, Burlington 05405.
Rosai
J
J
D008499:Medical Records / Q000592:standards*; D016347:Medical Records Systems, Computerized / Q000592:standards; D010340:Pathology, Surgical / Q000592:standards*