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Gastrointestinal (GI) diagnostic studies are pivotal in confirming, ruling out, diagnosing, or staging various diseases, including cancers. Following diagnosis, allocating time for discussions with the patient and providing informational resources is crucial. Diagnostic assessments of the GI tract often occur in outpatient settings like endoscopy suites or GI labs. Preparation for these tests may include dietary restrictions, fasting, liquid bowel preparations, laxatives, enemas, and the...
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[Standardized structured reports for gastrointestinal tumors].

Ekkehard Hewer1, Anna Rump2, Rupert Langer2

  • 1Institut universitaire de pathologie, Centre hospitalier universitaire vaudois (CHUV) et Université de Lausanne, Rue du Bugnon 25, 1011, Lausanne, Schweiz. ekkehard.hewer@unil.ch.

Der Pathologe
|October 5, 2021
PubMed
Summary

Synoptic reporting in pathology, using standardized checklists, enhances report completeness and patient care. Protocols from the College of American Pathologists (CAP) and International Collaboration for Cancer Reporting (ICCR) offer valuable, structured information for cancer diagnostics.

Keywords:
ChecklistData accuracyHealthcare quality assurancePathologyQuality control

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Area of Science:

  • Pathology
  • Medical Informatics

Background:

  • Traditional narrative pathology reports can lack completeness and comprehensibility.
  • Synoptic reporting offers a structured alternative using checklists and standardized formats.
  • Major institutions like CAP and ICCR provide synoptic reporting templates for various cancers.

Purpose of the Study:

  • To define synoptic reporting in pathology.
  • To highlight its benefits for report completeness, comprehensibility, and patient care.
  • To discuss implementation challenges, particularly in German reporting contexts.

Main Methods:

  • Comparison of synoptic reporting with traditional narrative reporting.
  • Analysis of templates and protocols from the College of American Pathologists (CAP) and International Collaboration for Cancer Reporting (ICCR).
  • Discussion of benefits and challenges of synoptic reporting implementation.

Main Results:

  • Synoptic reporting utilizes a laboratory value-like format and standardized checklists.
  • Synoptic protocols ensure completeness, standardized terminology, and uniform diagnostic criteria.
  • CAP and ICCR protocols serve as valuable information resources, even outside synoptic reporting.

Conclusions:

  • Synoptic reporting significantly improves pathology report quality and patient care.
  • Standardized protocols from CAP and ICCR are crucial resources for pathology.
  • Implementation requires addressing specific challenges, such as those in German reporting.