As described in the Optimal Resources for Cancer Care (2020 Standards), CoC Standards 5.3 (Sentinel Node Biopsy for Breast Cancer), 5.4 (Axillary Lymph Node Dissection for Breast Cancer), 5.5 (Wide Local Excision for Primary Cutaneous Melanoma), and 5.6 (Colon Resection) require operative reports to include specific elements and responses in synoptic format. For information on the timeline, compliance requirements, and the site visit process, please refer to the Timeline and Compliance Information page.
There are currently three mechanisms a center can use to create synoptic operative reports that conform to CoC Standards.
Create institutional synoptic reporting templates that capture only the required CoC elements and response options:
- Institutional templates must include the required elements and response options as outlined in the Optimal Resources for Cancer Care (2020 Standards). Elements and response options must use the same wording as in the CoC standard.
- To meet synoptic formatting requirements, the completed synoptic operative report must list each required data element followed by its response (answer) in a "diagnostic parameter pair" format. Providing the required data elements and responses in prose format does not meet these requirements.
- All required elements and responses must be listed together in one location in the operative report.
- The required data elements and responses can appear in a separate synoptic portion that complements a traditional narrative report. However, the required elements and responses must be in the operative report of record. They cannot be a part of the brief operative note.
- Many electronic medical records (EMRs) can create such templates.
- The required elements and responses from the Optimal Resources for Cancer Care (2020 Standards) can be shared with your institutional IT team and with your EMR support team, as needed, to build a synoptic solution for your facility.
- There are no fees associated with use of the content in the manual.
- Since the content of the Optimal Resources for Cancer Care (2020 Standards) is copyright of the American College of Surgeons, we would appreciate where possible that you acknowledge the ACS copyright: Copyright © 2019 American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611-3295. All rights reserved.
- Because the material is copyright protected, the material or tools built using this material must not be shared with commercial vendors or with other institutions.
Work with a third-party vendor to integrate their synoptic operative reporting tool:
- CoC-accredited cancer programs may opt to work with one of these third-party vendors to integrate their tool into the EMR.
- These tools are sufficiently comprehensive to replace the need for narrative reports and were built to integrate into the EMR.
- Working with these third-party vendors may involve an additional cost to programs.
- These tools were built from content in the synoptic operative reporting templates developed by the Cancer Surgery Standards Program (CSSP) for the documentation of melanoma, breast, and colon cancer surgery.
- The CSSP synoptic operative reporting templates contain a comprehensive list of data fields with intent of replacing the need for narrative reports.
- Data elements in these templates include fields required for compliance with CoC Standards 5.3–5.6 as well as universal surgical elements and elements required by other accrediting organizations.
- The templates, developed by surgeons with abundant user input, include American Joint Committee on Cancer (AJCC) TNM staging and National Cancer Database (NCDB) codes, where appropriate.
Use the fillable PDF forms downloaded from the Standards Resource Library:
- Programs that are unable to incorporate synoptic operative reporting tools into their EMR can utilize the four fillable PDF forms available for download from the Standards Resource Library in QPort.
- These forms were developed as a stop-gap measure to allow these programs to meet the synoptic formatting requirements of the standards.
- Using the fillable PDF forms is the only approved option for including the required elements and response options outside of the operative report of record.
- The fillable PDF forms are not completed via the ACS website. They must be downloaded and then completed for each case in addition to the routine clinical narrative reports.
- No data will be saved or downloaded to the ACS website.
- The local identifier field is optional and allows institutions to use their preferred clinical identifier as a manner of tracking cases for future site visits.
- Programs will be responsible for ensuring that these forms are secure and that processes are in place to manage the forms according to HIPAA rules and regulations.
- Following local policies and practices for patient privacy and security of protected information and seeking advice of local authorities as needed is strongly recommended.
The Operative Standards Toolkit provides educational resources to support the implementation of these standards, including a comprehensive FAQ with additional information on synoptic reporting.
The above information applies to CoC institutions only. Non-CoC institutions are requested to seek permission for use of ACS content. Please contact cssp@facs.org for information on copyright acknowledgement, permissions, or licensure. Questions about the requirements of the CoC Operative Standards or these implementation options should also be directed to cssp@facs.org.
