Template-based synoptic reports improve the quality of pathology reports of prostatectomy specimens

Aumann K, Amann D, Gumpp V, Hauschke D, Kayser G, May A M, Wetterauer U & Werner M (2012) Histopathology 60, 634–644 Template‐based synoptic reports improve the quality of pathology reports of prostatectomy specimens Aims: Traditionally, pathology reports have been textual, with a high degree of variability. In part, they miss some of the information needed, e.g. for therapy decisions. To meet all requirements, it would be helpful to have a tool providing reminders of the necessary data and facilitating the transfer of these data into a pathology information system (PIS). Here, we describe a TNM‐adapted toolset including a PIS‐integrated structured template that contributes to improving pathology reports of prostatectomy specimens. Methods and results: All prostatectomy reports between January 2002 and August 2010 (n = 1049) were classified into descriptive reports (DRs) (n = 411), structured reports (SRs) arranged according to tumour spread, lymph node status, and surgical margin status (n = 333), and template‐based synoptic reports (TBSRs) (n = 305). The report types were compared with regard to the content of 11 organ‐specific essential data (ED) items crucial for exact TNM classification, therapy decisions, or prognostication. All 11 ED items were included in 2.7% of DRs, 43.5% of SRs and 97.2% of TBSRs, with a statistically highly significant difference (P