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How to fill out the Synoptic Operative Report Templates online
Filling out the Synoptic Operative Report Templates is essential for capturing comprehensive information regarding breast cancer surgeries. This guide will help you navigate each section of the template to ensure that all relevant details are accurately recorded.
Follow the steps to complete the Synoptic Operative Report Templates online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by providing the clinical preamble as appropriate. This may include details such as marking, antibiotics, and radiology results.
- Fill in the 'Indication' section, selecting the appropriate reason for surgery, such as primary treatment or re-excision.
- Complete the 'Preoperative Biopsy' section by specifying the method used for biopsy, such as core biopsy by radiology or FNA.
- Provide the preoperative diagnosis. Select from options like invasive carcinoma or DCIS, or specify another diagnosis if applicable.
- In the 'Preoperative Stage' section, describe the size and clinical findings of the tumor.
- Document any neoadjuvant therapy received by the patient prior to surgery.
- Detail the 'Breast Procedure' performed, selecting all that apply, including partial mastectomy or total mastectomy.
- Fill out the 'Axillary Procedure' section with the type of procedure conducted, such as sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND).
- Complete the 'Operative Details' by reporting the specifics for incision type, intraoperative confirmation, and specimen orientation.
- Finalize the report by filling out the remaining sections in 'Procedure Completion,' including unplanned events or complications and closure details.
- After completing all required fields, ensure you save your changes. You can then download, print, or share the completed form as needed.
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Synoptic reporting is a process for reporting specific data elements in a specific format in surgical pathology reports. Previously, surgical pathology reports were free text, highly narrative, and prone to omission of necessary data and inconsistencies in formatting.
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