Documentation Challenges in Surgery

• Detailed operative reports with specific findings
• Time pressure between cases
• Pre-op and post-op documentation requirements
• Procedure-specific documentation templates
• Coordinating with anesthesia documentation

Note Types for Surgery

• Operative Note

  Detailed surgical procedure documentation

• Pre-Op Assessment

  Pre-operative evaluation and clearance

• Post-Op Check

  Post-operative day notes and wound checks

• Surgical Consult

  Surgical consultation recommendations

Key Features for Surgery

• Operative Templates

  Procedure-specific templates for common surgeries

• Quick Dictation

  Between-case documentation in minutes

• CPT Suggestions

  Appropriate surgical billing code recommendations

• Complication Tracking

  Documentation of intraoperative events

Stats

• 2 min - Op Report Time
• 15% - More Cases/Day
• 98% - Coding Accuracy
• Epic - Integration

Testimonial

I used to dictate op notes while driving home. Now they're done before I scrub out. Game changer for a busy surgical practice.