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Synoptic Reporting – Pros and Cons To provide excellent care for patients and adequately track medical outcomes, physicians require complete and quality clinical documentation. As electronic medical records are becoming popular with meaningful use, there is a growing significance for electronic documentation. Synoptic reporting is a documentation method that uses structured checklists to help physicians generate more complete, consistent and valuable medical reports. Synoptic reports are computer-based worksheets that allow medical professionals to enter and acquire information in a quicker and more accurate manner than free-text reports. This new technology is raising the bar across several medical disciplines, especially pathology, surgery, radiology and clinical research.
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More Complete Documentation – Synoptic reports apply comprehensive checklists to produce more complete documentation that helps in providing quality care. For example, the checklists in synoptic surgical reports have all the necessary information for diagnosis, prediction, prognosis and subsequent management of the patient. If it is difficult or impossible to specify an issue in a completely standardized format, you can put it as text commentary at the end of the synoptic report in the way you want.
Less Errors and Omissions – In synoptic reporting, data is entered into discrete fields. Often, templates are used to guide the physicians to enter the correct data. This will reduce dictation and transcription-related errors significantly. The template also ensures that no essential information is missing from the reports.
Easy to Read and Understand – Not only are the synoptic reports simpler to produce than free-text reporting, they are also simpler to read and understand. The verbiage of certain traditional reports may conceal critical information. You are more likely to get the core information more quickly while reading something as a bulleted list rather than reading an entire report.
Finish Reports Faster – Since the synoptic style doesn’t require narration or dictation, you can complete your reports faster. The reports are immediately inserted into patients’ charts as well.
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Easily Searchable Reports – Synoptic reports make use of templates to streamline your reports. This makes it easy for consulting physicians to locate the information quickly in times of need. As it won’t take hours to search through your patient reports, you can cover common variables and treatment plans faster and determine quickly which course of treatment works best for your patients.
Drawbacks
Excessive Data – If you are not configuring your own mandatory fields, synoptic reporting system may flood your reports with unnecessary data fields. You will find yourself repeatedly choosing ‘Not Applicable’ or entering irrelevant information.
As a result, you may not benefit from the time
savings offered by this style of reporting. You may have to use smart synoptic software with configurable mandatory fields smart branching to get over this issue.
Lack of Narrative Data – Narrative reports are essential in complex cases and synoptic reports may fail to provide enough data in such cases. The rigidity of choices may not reflect the complexity. Though it is possible to document complex cases without relying completely on narrative reporting, you may require synoptic software that enables you to configure new data and free text fields.
Interoperability Problems – Even though synoptic reports are easier to read, there is no use if it is not possible to integrate your data with your existing systems. No one will be able to read your reports. In other words, if
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www.medicaltranscriptionservicecompany.com you are using lab information system for communicating with other clinicians, you require synoptic reporting software that can communicate with your system. HL7 operability is a must for system integration. You may require a software developer who can build a custom interface to ensure your software works with all systems.
Issues with Mobility and Compatibility – Healthcare practices require reporting software compatible with not just desktop, but a wide range of platforms such as iPads, iPhones, Android devices and so on. Finding and implementing such kind of synoptic software is quite challenging.
User Interface Troubles – Sometimes the user interface of synoptic software remains quite confusing. Even though the software stays efficient, this makes it hard to work with it.
Why Medical Transcription Is Still Important
Though synoptic reporting is advantageous, the above mentioned drawbacks imply that it can’t lead to the demise of transcription. Human intervention is still important to achieve completeness and accuracy of clinical documentation. Combining the efforts of medical transcriptionists and discrete reportable transcription (DRT) technology, you can produce complete and accurate documentation with Electronic Medical Records (EMR), especially in complex cases. The transcriptionists will transcribe the physician dictation and the transcribed data can be populated into relevant fields in the electronic record system. Professional medical transcription companies offer the service of a QA team that will review the transcribed data, resolve the errors and edit the data if necessary, before sending it to the EMR
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www.medicaltranscriptionservicecompany.com system. In this way, EMR transcription resolves two major challenges with electronic documentation such as copy-paste errors and limitations to narrative style. However, it is up to the practices to decide whether synoptic reporting or EMR transcription or adopting both approaches will work for them best. Practices must thoroughly understand their needs to make the right choice.
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