Uptake and impact of synoptic reporting in a community care setting.

ABSTRACT

BACKGROUND: Breast cancer surgeries have traditionally been documented in narrative reports. Narrative reports have been shown to be incomplete. Synoptic reports utilize standardized templates to record data and have emerged as an alternative to narrative reports. This study evaluates the uptake and impact of synoptic reporting for breast cancer surgery in a community care setting. METHODS: A retrospective review of operative reports documenting breast cancer surgeries over a consecutive 3-year period. RESULTS: 772 narrative reports and 158 synoptic reports were reviewed. Synoptic reports were associated with a higher degree of overall completeness (60% vs 45%) when compared to narrative reports. 6 out of 7 surgeons that produced at least 5 synoptic and 5 narrative reports had increases in completeness with use of synoptic reporting. CONCLUSIONS: Use of synoptic reporting improves breast cancer operative report completeness and decreases superfluous content when compared to narrative reports. While synoptic report uptake during the study period was suboptimal there exists several means by which it can be improved, including investment in information technology infrastructure and emphasis on stakeholder engagement.