ComplyMD: Surgeon Notes for Documentation

ComplyMD offers Surgeon Notes for physician’s OR documentation. It’s a tough job to capture the physician’s attention while he/she’s in the OR. The focus is on the patient – where it should very well be. But, once physicians are done with procedures, where does their attention go? Oftentimes, they’ll pick up a dictaphone, or jot down notes on their index card, or even rotate into the very next OR to begin the next procedure. ComplyMD is different. It can almost appear as disruptive, but don’t let that scare you away from the concept. ComplyMD captures the physician’s attention and directs it towards accurate, real-time, rich documentation of exactly what went on in that very OR with that very patient. And after documenting with ComplyMD Surgeon Notes, the physician is done. That’s it.

Better Documentation – Why It’s So Crucial

A great article by Selena Chavis in For The Record magazine, gives us all a little insight into WHY documentation is so important. A few of the summarized reasons include:
• Quality of patient care
• Patient safety and outcomes
• Compliance
• Revenue cycle management

So we see that documentation doesn’t just affect compliance and revenue cycle management….it extends all the way to patient safety and quality of care. Think about it: Of course better documentation would give you a better picture of what’s really going on with your patient, thus you are able to make better decisions for their course of care.

Chief privacy officer and executive director with Georgia-based Wellstar Health System, Beth Kost-Woodrow says, “[Better documentation is] the one piece that sets the stage for success or failure in many areas of hospital operations and patient care.” I believe she is right. Better documentation not only affects the facility, but the physician as well. “As hospital and physician profiling on the Internet has increased scrutiny, many experts suggest that attitudes are changing and the time may be ripe for a renewed focus on documentation improvement programs.”

Canned Operative Reports: How They Can Work For You

“Advise surgeons to avoid the use of “canned” op reports. You know what these are; all the op reports for a particular type of surgery look exactly the same. Most often canned reports will show up for cataract, pain management, and sometimes gastro-intestinal procedures, but they can occur with any specialty.

Medicare and other payers frown on the use of “canned” op reports to document procedures. They can also be an issue for both the ASC’s and physician’s malpractice insurance carrier—such as when complications aren’t documented in the rare instance when they do occur.

If the physician performs similar procedures and wishes to use some sort of template, he or she must tailor it adequately to each patient’s individual surgery and circumstances for use, and it shouldn’t appear to be ‘canned.’”

“Tip: Avoid ‘Canned’ Op Reports”. Ellis Medical Consulting, Inc. Ambulatory Surgery Reimbursement Update. HCPro. May 2008.

Canned operative reports can work against you, if used in the wrong way. However, our approach to canned reports greatly differs. Many physicians perform the same procedures over and over and over again; therefore, dictating much of the same information over and over and over again, with slight variations here and there according to complications and specific patient information. With repetitious dictation, facilities will incur unnecessary transcription costs for this dictation. Not only is repetitious dictation unnecessarily costly, it’s time consuming for the physician. ComplyMD’s web-based software enables physicians to document procedures (in code-ready language), attaching their own customized canned operative report, already typed and ready to be sent to the coder’s office.

Pay-for-Performance: Will you be a loser?

“Pay-for-performance reimbursement plans and consumer-directed health plans both depend on assessing and distributing information on clinical performance. Physicians who don’t have the means to track their own clinical results will be losers, literally, of patient volume and revenues.”

“Medicare Quality Codes & Their Impact on Physicians” ICLOPS, LLC. December 2005

With these new plans and governmental mandates, physicians need to be equipped with the tools to properly, easily and efficiently track their own clinical results. Capturing appropriate documentation of diagnoses and procedures will result in capturing appropriate revenue for the facility and the physician. ComplyMD is a web-based application located inside or immediately outside the OR to help physicians capture appropriate documentation, at the point of service. The more time physicians wait to document (dictate) their procedures, the more room they leave for error in their documentation.

ComplyMD gives physicians multiple choice lists of proper, code-ready documentation of diagnoses and procedures. It creates a comprehensive operative note for the patient encounter that’s ready to be sent to the coder’s office, immediately after the procedure. ComplyMD gives physicians the tools to track their own results so they will not be losers of patient volume and revenues, and their facilities will not be found as losers either.