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Click ‘Get Form’ to open the Breast Cancer Synoptic Operative Report Template in our editor.
Begin with the Clinical Preamble section. Dictate relevant details such as marking, antibiotics, and radiology results as appropriate.
Move to the Summary Report section. List the 18 essential data elements by specifying each element number, name, and response (e.g., '1. Indication: Primary Treatment').
For a Complete Report, ensure you dictate all 28 data elements in a similar format. Remember to repeat this for bilateral cases.
Fill out the Operative Details sections for both Breast and Axilla procedures, selecting applicable options and providing narrative where necessary.
Conclude with Procedure Completion by noting any unplanned events or complications and detailing closure methods.
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The operative report is perhaps the single most important document in a surgical chart. It is the official document that captures what transpired in the operating room. It must support the medical necessity for treating the patient, describe each part of the surgical procedure(s), and reveal the results of the surgery.
What is synoptic operative reporting?
Specimen Analysis Report Operative reports: Synoptic operative reports document essential elements including procedure, findings, complications, and postoperative instructions.
What is a synoptic report?
The NBCC Synoptic imaging report is lesion based, tracking individual lesions and considering mammography and ultrasound characteristics for each lesion in the same section rather than reporting the imaging findings separately requiring the radiologist to offer one classification finding per lesion.
What is a synoptic operative report?
Introduction to Synoptic Operative Reporting These standards docHubly alter the format in which operative reports are written by surgeons. The synoptic format contains standardized data elements organized as a structured checklist or template, with a choice of pre-determined values for each data element.
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The synoptic diagram of the hall can be freely shaped: it is possible to create a structure, to place microphone units in an interactive way, to assign several.
Design and implementation of synoptic operative report
by W Bonney 2013 Cited by 7 Synoptic operative report templates enable clinicians to capture and display succinct clinical information in a standardized and logical manner. Synoptic
by FA Shaikh 2019 Cited by 6 Electronic synoptic operative reporting: assessing the reliability and completeness of synoptic reports for pancreatic resection.J Am Coll Surg.2010;211:308-15.
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