The College of American Pathologists (CAP) periodically releases new editions of its Laboratory Accreditation Program checklists. CAP inspectors use these checklists during inspections to ensure laboratories comply with the Centers for Medicare and Medicaid Services (CMS) regulations and achieve accreditation. The CMS regulates all laboratory testing performed on humans in the United States (except research and clinical trials) through the Clinical Laboratory Improvement Amendments (CLIA).
CAP is a CMS-approved accreditation organization with deeming authority to inspect laboratories under CLIA.
Anatomical pathology reporting has historically been narrative. However, there is a movement toward standardized descriptions using digital technology. In practice, CAP has promoted synoptic reporting for many years and has published protocols with required and optional data elements.
Some speech recognition systems offer reporting modules where the gross templates are formatted automatically to laboratory standards. This allows for easier capture of discrete data in the synoptic reports. The software’s CAP eCC (electronic Cancer Checklists) synoptic module provides solid support for the CAP cancer reporting requirements and the contents of the American Joint Commission on Cancer (AJCC) TMN staging system.6
