Healthcare is often complicated, with numerous physicians of various specialties seeing the same patient. Ideally, all physicians involved with the care of a given patient would meet frequently to discuss and update each other on the care they have provided. Such is not feasible for many due to busy schedules and lack of time, leaving recent clinical reports as the most convenient way to keep track of patient care. Often is the case however that each provider have his or her own report format and nomenclature, which can make inter-physician report comprehension very difficult. Structured reporting can help improve communication in three major ways.
1. Standardized Nomenclature & Terminology
Standardized nomenclature and terminology in reports ensure that everyone is speaking the same language. Structured reporting utilizes customizable templates that are pre-configured to contain the same nomenclature for all users. Report templates can be set with accreditation standard terminology and administered across the healthcare organization for easier understanding and communication.
2. Automatic Universal Format
Structured reports promote a common format and section order within an organization. With structured reporting, reports are automatically generated and formatted through user-chosen dropdown menus, checkboxes, and text fields. All reports follow the same format, with data always in the same order, for quick comprehension and easy understanding.
3. Data completeness
Structured reports allow for confidence that all required information is always documented for maximum comprehension of patient health. Dictated or free-written reports contain what the writer believes to be most clinically important, but might not capture all data required by other members of the care team and accreditation body. Structured reporting workflow guides the user through each section of the report and presents all options to report with certain data required to save the report.
High-quality healthcare, with the best possible outcomes, hinges on fluid inter-physician communication to enable coordination across the care team. Without the time for regular meetings amongst themselves, members of the care team rely on clinical reports to understand the patient’s condition. Structured reports allow for quick and easy understanding through standardized nomenclature and universal format, and ensure that all the data needed across the care team is collected.
Contact us to learn more about how VidiStar structured reporting can help improve communication within your organization.
Written by Michael Rachmilowitz, Informatics Product Manager, Hitachi Healthcare Americas