Presented at the 1998 APIII Conference Return to 1998 Abstract Index
ELECTRONIC WORKSHEETS FOR PRODUCING SYNOPTIC PATHOLOGY REPORTS
Saint Joseph Hospital
Department of Pathology
Augusta, Georgia
David L. Booker, MD
For several years, pathologists have recognized the need
to standardize anatomic pathology reporting, but standardized
or “synoptic” reporting has not become widespread
for several reasons. Pathology organizations have published
guidelines, but they vary in format, arrangement, and organization.
They exist for only a small number of specimens and must
be obtained from an inconvenient variety of sources. They
contain limited supporting information and have not been
designed to exploit the use of the computer for creating
reports, for education, or for quality improvement activities.
Our electronic worksheets overcome these shortcomings.
Synoptic Pathology Report Worksheets© consists of approximately
400 worksheets with which virtually any gross description
or diagnostic report may be generated. It exploits the power
of the computer to organize and link large amounts of data
using standard word-processing software. Logically organized
worksheets are easily accessed using the Windows Explorer.
Each worksheet is composed of multiple subdocuments (selected from a total of 1,200 subdocuments); many are shared by other worksheets. This promotes uniformity and simplifies updating. Subdocuments contain a menu of selections and may contain or have hyperlinks to supporting information such as staging data, diagnostic criteria, literature references, images, and Internet sites. Subdocuments are organized in a similar manner in all specimen types, and their use results in comprehensive synoptic reports with consistent terminology and format.
Clinicians have praised reports generated with these worksheets in our private practice. Through further development of content and functionality, these worksheets could be extremely useful in pathology practice, education, and quality improvement.
