ACC/AHA/SCAI 2014 health policy statement on structured reporting for the cardiac catheterization laboratory: A report of the american college of cardiology clinical quality committee
The final report is an essential component of every invasive and operative procedure. This vital document records key data used to assess indications and appropriateness of care, details technical aspects of the procedure, describes findings and observations, lists results and calculations, provides the interpretation of the study, and conveys patient care recommendations. In addition to providing essential information to the entire team of care providers, the final report is utilized in billing and inventory management, process and performance improvement, outcomes analysis, teaching and education, and as a data source for registries. 1 The final report is a legal medical record document and should be of the highest quality so as to optimize both patient outcomes and institutional operational efficiencies. A structured report generated by a structured reporting process is the most suitable vehicle for these goals, but this approach is only slowly being adopted despite prior recommendations and endorsements. This HPS is intended to provide a general model for structured reporting for invasive and interventional cardiovascular procedures and thus catalyze and accelerate implementation of structured reporting. Through endorsement of this document, the cardiovascular community recognizes the critical importance of structured reporting and calls for its uniform adoption. The general principles of structured reporting in cardiovascular imaging are well established. Information should be captured as data rather than prose; these data should flow bidirectionally to and from the EHR for subsequent presentation and analysis. The final report should be clear, concise, organized, consistent, reproducible, understandable, and in a format that is flexible to accommodate evolutionary procedural changes and documentation requirements. Key considerations for generating a structured report are discussed in detail, with a structured procedure report prototype included for modeling purposes. The prototype final report is segmented into 3 principal sections. The first section (front page) is a single (physical) page that contains the highest value clinical information. Because angiography is inherently visual, the second section is dedicated to the graphical representations of the findings and (optionally) images imported into the report. The body (third section) contains all of the remaining data presented as a series of structured, formatted tables. Procedure-specific content is outlined for diagnostic cardiac catheterization, percutaneous coronary intervention (PCI), peripheral vascular and cerebral vascular procedures, valvular heart disease including transcatheter aortic valve replacement (TAVR), structural and congenital heart disease (CHD), and combination procedures. The concepts enumerated in this HPS are applicable to nonsurgical endovascular procedures performed in a cardiac catheterization laboratory, hybrid catheterization/operating room suite, and interventional/neuroradiology suite. Universal adoption of structured reporting for invasive cardiovascular imaging procedures requires the acknowledgment of its potential benefits and acceptance of the responsibilities entailed. In order to stimulate structured reporting implementation, key groups including physician operators, catheterization laboratory personnel, the software vendor community, and leadership of registries must be on the forefront of advocating the adoption of structured reporting. The ACC/AHA/ Society for Cardiovascular Angiography and Interventions Foundation (SCAI) recognize that the development and deployment of structured reporting will be an ongoing process and, therefore, strongly encourage the view that structured reporting be considered one component of the overall quality improvement imperative for cardiovascular care. © 2014 by the American College of Cardiology Foundation, the American Heart Association, Inc.
Sanborn, TA; Tcheng, JE; Anderson, HV; Chambers, CE; Cheatham, SL; Decaro, MV; Durack, JC; Everett, AD; Gordon, JB; Hammond, WE; Hijazi, ZM; Kashyap, VS; Knudtson, M; Landzberg, MJ; Martinez-Rios, MA; Riggs, LA; Sim, KH; Slotwiner, DJ; Solomon, H; Szeto, WY; Weiner, BH; Weintraub, WS; Windle, JR
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