Developing Synoptic Checklist for Reporting of Six Major Malignant Tumors in Taiwan Based on Taiwan Cancer Registry Coding Manual (TCRCM), College of American Pathologists (CAP), American Joint Committee on Cancer (AJCC), and World Health Organization (WHO) Classification
Pei-Yi Chu MD; Changhua Christian Hospital; Ya-Fen Liang MSN; Changhua Christian Hospital; Ren-Hung Huang MD; Changhua Christian Hospital; Bey-Leei Ling MD; Changhua Christian Hospital;
Content:
National cancer registration of six major malignant tumors, colorectal cancer, lung cancer, breast cancer, oral cancer, liver cancer, and cervical cancer, in Taiwan has been administrated for 5 years in major medical centers. Free text format of pathology reports is criticized by clinician and structured data formats are highly recommended for clearly and efficiently understanding. To meet the requirement for covering essential pathological factors of six major malignant tumors, appropriate pathology report formats are needed.
Technology:
The purpose of our project was to develop the whole set of essential pathological factors in the synoptic checklist for six major malignant tumors by reference of TCRCM, CAP, AJCC, and WHO classification. Various elements such as tumor size, tumor type, tumor macroscopic and microscopic characters, regional lymph node status, tumor staging, immunohistochemical study, and etc. are included.
Design:
A synoptic reporting system for generation of the histology reports of six major tumors, which included canned files classified by various tumor locations and behaviors, preformatted templates, tabular data entry sheets, and blank spaces for additional pathological findings entry. Several additional codes, such as, SNOMED, pathology quality indicators, intradepartmental or interdepartmental consultation, teaching or research materials and etc are incorporated into the synoptic reporting system.
Results:
The synoptic reporting system we designed shows advantages of (1) saving the reporting time of pathologists and reading time of clinicians, (2) better understanding of pathology reports, (3) significantly reducing typing time and typing errors, (4) easily picking up with desired pathological elements for research or teaching purpose, (5) unifying the pathology report signed out by different pathologists, (6) incorporating the pathologic data easily into the TCRCM.
Conclusion:
The synoptic checklists for pathology reports we developed provided not only diagnostic elements but also prognostic factors of tumor specimens. Standardization, uniformity, consistency, and easily retrieval of pathology report element can be achieved to make better clinical management of patients and national epidemiologic survey.
