To be the most effective, structured reporting uses the application of vocabulary and data interoperability standards, as well as the use of best practice workflows (industrial engineering). This has the benefit of reducing provider time to complete reports, as well as improving clinical communication among physicians, the care team, and patients. The ACC encourages cardiovascular clinicians to convert from a dictation model to a structured data model in the Cath lab.

Structured Reporting in the Cath Lab

Converting from a dictation model to a structured model does require some initial work. It will require cooperation with internal IT systems and vendors in order to ensure the information model and systems are aligned with clinical model. A sample structure is below:

Pre-Procedure

Who: Ordering physician [Pre-procedure evaluation by operator]

What information: Patient demographics, requested procedure, scheduling logistics, procedure indications, clinical history

What information as data: Demographics, ICD-9 indications, structured history

Output: Structured H&P

Procedure

Who: CV Technologist / Nurse

What information: Procedure log, procedure findings

What information as data: Hemodynamics, medications, procedures performed, devices used / implanted, medications – basically everything

Output: Structured procedure data (in tables)

Analyze and Recompile

Who: Physician (with the aid of the computer)

What information: Findings and interpretations (physician)

What information as data: Compiled H&P, procedure data, and structured findings

Outputs: Procedure log and Procedure report

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