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Synoptic pathology reporting uses an electronic report in discrete data field format. That means each type of information has a specific place and format in the report. Synoptic reports standardize the way data is collected, transmitted, stored, retrieved and shared between clinical information systems.
An operative report is dictated by the surgeon immediately after the procedure, detailing who did what to whom using what materials and methods. Operation reports also include dictations that surgeons or their assistants complete after operative procedures.
Previously, surgical pathology reports were free text, highly narrative, and prone to omission of necessary data and inconsistencies in formatting. Synoptic reporting not only ensures that all reports contain all necessary data elements, but also is amenable to scalable data capture, interoperability, and exchange.
The synoptic operative report is a valuable teaching tool in the education of surgical residents. Documentation aside, this method of reporting enhances a surgical residents understanding of the perioperative preparation of a patient as well as the steps in the conduct of a surgical procedure.
The operative report is a narrative documenting a patients operative procedure and serves multiple purposes. It is a medical document which provides critical information to current and future health care providers.
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Start with the basicsmake sure every op note includes standard information such as: Patient Name. Date. Surgeon Name. Assistant Surgeon/Co‐surgeon. Applicable Pre-operative Diagnostics. Post-operative Diagnosis. Procedure. Changes to Planned Procedure.

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