nuance surgical capd

Consulting Services Surgical CAPD

Version: 4.7 February 2022

Nuance Surgical CAPD End User Guide v4.7 February 2022



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Table of Contents Purpose 5

Related Documentation 5

Audience 5

Assumptions 5

In-Application Assistance 5

Why Nuance Surgical CAPD – Value Statement 6

Accessing Surgical CAPD 7

Surgical CAPD Launchpad 9

Navigation Bar 9

LaunchPad – View Daily Schedule of Patients 12

More Actions 12

Daily Schedules 13

Creating a New Report in Surgical CAPD 13

Custom Descriptions and Reports 28

Creating and Using Variables 33

Creating Custom Reports from Transcription Templates 35

Addendum of Report 38

Changing the Patient on the Report 39

Admin Settings 41

Customizing Account Settings 43

Surgical CAPD Mobile Application Overview 47

Surgical CAPD Mobile Application Workflow 48

Adding Images 53



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© 2022 Nuance Communications, Inc. All rights reserved. 5

Purpose This document is intended as comprehensive guide for End Users utilizing Nuance Surgical CAPD.

Related Documentation For supplemental information, see the following document(s):

• Quick Reference Guides

Audience The audience for this guide is providers, physicians, mid-levels, and nurses who plan to utilize the Surgical CAPD software.

Assumptions This document assumes you are familiar with:

• Basic computer functions

• EHR basic functions

In-Application Assistance

• The Question Mark with purple background and number indicates there are written reference materials available, such as Manuals and Quick Reference Guides. The number represents the number of available documents.

• The information icon is located within the headers of Diagnoses & Procedures, General Information, Technique, Associated Providers, Charge Capture, and Report Preview. Short videos and functional descriptions of each section are found when clicking the icon.




Why Nuance Surgical CAPD – Value Statement Nuance Surgical CAPD empowers Physicians with in-workflow guidance to improve real-time clinical documentation. In-workflow guidance efficiently improves document specificity and improves reimbursement outcomes. Intelligent workflows guide the capture of all requirements for ICD-10 specificity and Joint Commission delivering compliant notes that reflect the level of care provided.

Nuance Surgical CAPD uses Artificial Intelligence (AI) to improve Documentation, Revenue, and Patient Safety. AI-driven workflow promotes appropriate reimbursement, patient care, and quality outcomes based on complete operative reports that capture fully specified procedures and diagnoses.

Artificial Intelligence (AI) tools are becoming widely used to document complete operative reports that meet the latest documentation requirements immediately after surgery, ensuring that care teams, coders, and other key documentation stakeholders have complete and accurate information immediately without adding time for the surgeon. This process has tremendous benefits to patient care, accurate and appropriate coding, wRVU (work relative value units) capture, reimbursement, and quality metrics.

For every patient examination or procedure performed, Surgeons receive a certain amount of work RVUs. The wRVU is then multiplied by a conversion factor, which is a specific dollar amount. Every CPT code used for Medicare and Medicaid billing has a corresponding wRVU.

• Faster documentation workflow.

o Real-time documentation of cases in one pass.

o Reduce coding queries.

o Provide care teams with immediate access to detailed full reports.

o Receive case tracking and discrete data capture for research and analytics.

• Real-time documentation assistance.

o Real-time advice presented at the point of care.

o Capture more specific and compliant details.

o Dynamic templates outline for common procedures to speed documentation.

• Eliminate transcription.

o Personalized workflows make it easy to quickly capture narratives.

o The mobile app allows clinicians to quickly review schedules and create reports on the go.

• Accelerate the revenue cycle.

o Immediate decrease in DNFB (discharged no final bill).

o Automated charge capture report sent to clinician offices.

o Documentation and coding gaps disappear, bills can be ready in just two hours.

o Workflow documentation is geared for clear understanding by coding professionals which in turn enhances the revenue cycle and speed to reimbursement.




Accessing Surgical CAPD

Web/Desktop Access

• Google Chrome is the recommended browser to be used for Surgical CAPD

• Go to https://app.nuancesurgicalcapd.com/accounts/login

• Enter your login credentials (username and password)

• Click “LOGIN”

• If using a voice-to-text solution, extensions may need to be enabled or allowed at the time of log in

NOTE: Your facility may have a Surgical CAPD desktop icon that will navigate straight to the login page.

NOTE: Password Criteria includes the following:

1. Password must not contain username

2. Password length must be between minimum 8 to maximum 256 characters

Passwords must meet 4 out of the following 4 complexity rules: - English uppercase characters (A…Z) - English lowercase characters (a…z) - Numeric digits (0…9) - Special characters (!@#$% …)

https://app.nuancesurgicalcapd.com/accounts/login




24/7 Assistance

A toll-free number and e-mail are available on the login Page for Surgical CAPD. Be certain to default to your organization’s protocol for the reporting of issues or problems. If you choose to send an e-mail be sure to include:

• First Name and Last Name

• Phone and other contact information if you want to be contacted

• Facility and or Hospital you are associated

Application Store Access (Android, iOS – Phone and Tablet)

If access the Surgical CAPD from our url: https://app.nuancesurgicalcapd.com/accounts/login from a smart device (Android/iOS - Phone or Tablet); users can select the appropriate tile, which should take you to the app in application store for your device.

Note: Fingerprint quick login into the mobile application is possible, if allowed.

Note: It is a Nuance Best Practice and suggested workflow. Training and setup of templates begin in the desktop application, and then move to the mobile app after templates have been created for ease of use.

Single Sign-On Access (Accessing Surgical CAPD from within your EHR system)

• Log into your EHR system

• Find and select the patient the clinician would like to document

• Click the Surgical CAPD tab within the EHR

• You are automatically logged into Nuance Surgical CAPD

https://app.nuancesurgicalcapd.com/accounts/login




Single Sign-On Access (Accesses Surgical CAPD using Active Directory Credentials)

• Go to your facility sign-in page for Surgical CAPD. This will be something like: facility_name.nuancesurgicalcapd.com. Facilities will have a desktop icon set up to direct users to this link.

• Enter your login credentials (Active Directory username and password, this may be the same and as the desktop or EHR)

• Click “LOGIN”

• Upon login, you will be redirected to the Surgical CAPD Launchpad page

Surgical CAPD Launchpad Surgical CAPD opens on the Launchpad. Access your Daily Schedules and Notifications on this page. The Launchpad enables a view of daily schedules. Clinicians can view and search patients and reports, begin new reports, and view notifications for reports that need your attention.

NOTE: If you access Surgical CAPD through your EHR, you will skip this page and land directly on the Patient Profile page. From that page, select “Begin” or “Create New Report”.

Navigation Bar The Navigation bar at the top of the Launchpad allows you to navigate between tabs at any time.




Patients Button

Click Patients button on the navigation bar if you do not have any cases scheduled for the day or a patient does not appear on your schedule. Here you can search for your patients to create a new report or add a patient to your daily schedule. You can search patients by:

• Patient Name

• Medical record number (MRN)

• Account number

Reports Button

Click the Reports button on the navigation bar and search by provider name to access:

• Search by Provider Name

o Reports that have been completed

o Reports to be completed

o Scheduled surgical encounters that appear on the schedule in the past and future with no report

Admin Button

Click the Admin button on the navigation bar to:

• Create New Users (Non-Physician Roles)

o Always defer to the site guidance and rules when using this feature

• Create and Edit Fax Listing

o This can also be managed by a local admin

• Create Patient Instructions

o Providers can create custom patient instructions associated with specific CPT codes which will be available to print along with the Charge Capture Report after e-sign.

o In most cases this function is part of an EHR discharge workflow handled by the nurse discharging the patient.




Create New Button

Click the Create New button on the navigation bar to:

• Create and schedule a report for today, yesterday, tomorrow, or another date

• Select the ‘Schedule and add another’ checkbox to schedule multiple reports without having to leave the page.

• Create a new report on a patient not appearing on the schedule but can be searched in Surgical CAPD.

• Create a new report for a patient not appearing in Surgical CAPD. Manual entry of patient information can be added, and report completed.

• New Custom Reports can be created with no patient associated to the report

• This is a good option when creating Custom Templates as it avoids document submission errors

•

Notifications

Prep the local environment to display the following notifications or review the information below.

E-Sign: A signature is required as part of a Midlevel (PA-C, NP) process where the Midlevel has saved as

Pending Approval.

Complete Requirements: A Midlevel or Provider has saved a report as Approval Pending without required

elements completed such as Diagnosis and Procedure.




Continue: Report was saved as a Work in Progress. This is often done as part of the pre-procedure prep.

Begin: Click Begin to start a new report.

LaunchPad – View Daily Schedule of Patients

Upon login, the daily schedule is immediately available. A provider may scroll or search for their patient and click BEGIN.

NOTE: Schedule does not appear in chronological order. Be certain the correct patient is selected.

More Actions The More Actions button next to the patient on the LaunchPad provides access to specific functions

without beginning the report in and accessing the report builder. Click to select any of the listed actions.

Cancel Report

Change Date Of Procedure

Edit Patent Information

Fax

Go To Patient

In Error

Inactivate Report

Print

Print Text




NOTE: You can choose to:

• Cancel a report if the operation or procedure did not occur.

• Inactivate a report if the operation or procedure occurred but was documented in another system.

Daily Schedules

View the schedule for “Today,” “Yesterday,” or “Tomorrow” directly on the Launchpad under this tab. Use “Other” for viewing the schedule for a specific date.

• Find your patient for the day and click to start creating your report.

• To preview the report, select anywhere in the operative report sticker other than the green “Begin” button.

Creating a New Report in Surgical CAPD Begin your report in one of the following ways:

• Find your patient for the day under the “Daily Schedule” and click to start your report.

• If you have no patients under the Daily Schedule section, click on the Navigation bar to

search and select your patient. Then click or .

• If your patient is not listed in the system, click on the Navigation bar. Demographic information regarding the patient will need to be entered manually.

NOTE: Using the “Create New” button is a great way to access the builder to create or adjust Custom Descriptions and Custom Reports without having to be in a patient encounter.

SCAPD Menu

Nuance Surgical CAPD Report Builder is where the reports are created. This is done by using the Left-Hand Panel and filling out the information in the various fields. Our goal is to complete the required fields changing them from red to green. Proper completion of this area may improve reimbursement turnaround time and wRVU revenue factors.

• Required fields are indicated by the Red .




• The Yellow indicates additional information is needed to generate the proper diagnosis code, however, this is not required to sign the note.

• The grey /dot may also appear in this area indicating greater specificity may be needed which does not impact coding level.

• Our goal is to have the Green for required elements.

• As diagnoses and procedures are searched, entered, and made a favorite, Surgical CAPD learns and remembers the common selections and related diagnoses and procedures associated with provider behavior.

Diagnoses and Procedures

This is an important step in the successful use of Surgical CAPD. Pre and Post-Operative Diagnoses and Procedures Performed elements are required for suggested ICD-10 charge capture. The green should be present after these areas are completed.

Position your cursor in any of the text boxes to start the report. Information can be entered by typing, using a speech-to-text system such as Dragon Medical One, or another speech-to-text solution. The Diagnoses and Procedures incorporate a decision tree functionality where a generalized entry leads to specificity questions for accurate charge capture. All selections can be saved as part of an initial template.

The search for the specific diagnosis is a keyword search which can begin with as small of an entry as part of a word, body part or anatomy, or core procedure. The system-generated specificity questions should drill down to the most specific diagnosis. Our Best Practice is to start with a broad generality as a single or partial word entry and create specificity within the note by answering the related specificity questions.

The Dynamic AI-driven nature of this section is key to the value of this solution. It is this section that drives greater specificity in Surgical CAPD.




Pre-Operative and Post-Operative Diagnoses

Diagnoses Entry Example:

Initial manual entry to find Symptomatic Cholelithiasis: sym cho

o Select Symptomatic Cholelithiasis from the list of suggestions

Select from system-generated specificity questions:

o Calculus of Bile Duct, with Cholangitis

▪ With Acute Cholangitis

• Enter the Pre-Operative Diagnoses

o Automatic decision tree prompts will drive documentation specificity.

o Add multiple diagnoses by clicking back into the search box.

o Click to delete any unwanted information.

o Click

• If the Pre-Operative Diagnoses and Post-Operative Diagnoses are the same, click

to automatically fill out the Post-Operative Diagnoses field.

NOTE: Begin by entering the Procedure Performed first will automatically improve the offering in the dropdown list for Pre-Operative and Post-Operative Diagnoses.

NOTE: When multiple Diagnoses and Procedures are entered, we can change the order of what has been entered by left clicking on the entries and dragging to the correct position and priority.

NOTE: Often after entering a Diagnosis or Procedure, there will be an opportunity to add notes regarding Symptoms and Surgical Technique. This an opportunity for greater specificity which may be difficult to define in other ways.




Procedures Performed

• Enter the Procedure name or title.

• Automatic decision tree prompts may drive documentation specificity.

• Additional clarifying statements can be made in the “Notes” field.

• To add a custom procedure when there is no reference in SCAPD:

o Enter the name of the procedure

o Click on the right-hand side of the search box or hit “Enter” on the keyboard

NOTE: The addition of a freehand entry to Surgical CAPD does not generate charge capture or specificity questions and may lead to lower wrvu values.

Procedure Entry Example

Procedure- Robot-assisted laparoscopic cholecystectomy, with cholangiogram

o Enter- Esophagoscopy, Select- Scope Type, Add- Additional procedure

• In many cases, Surgical CAPD will prompt the completion of an image, which can be marked or drawn on using the cursor. This functionality is optional.

NOTE:

• Fields with are required by The Joint Commission and must be filled out to E-Sign the report.

• Be sure your cursor is in the text box before inputting any information.

• The before a diagnosis indicates it has been marked as a favorite. Favorite diagnoses will always flow to the top of the list for easy access on future reports.

• If you search for a term that requires specificity, Surgical CAPD will prompt you to be more specific.

• The signifies that specifiers are available but are not required. The report can be E-Signed with this appearing.

• Any additional information should be included in the “Notes” section.

• If you have multiple procedures, you can drag the primary procedure to the top by clicking and dragging it above the other procedures. This can be done for diagnoses as well.

• If you have the ICD-10 Procedure code, you can search using that code. This is only available in the procedure area.




General Information

The section on the left-hand panel is where you will enter information specific to your case, such as Anesthesia, Blood Loss, Specimens Removed, Assistants, etc. Any fields that are required by The

Joint Commission are indicated by a .

• 1: Click in the left-hand panel beside “General Information” to add additional fields to document further information.

• 2: Select the fields that you require. These selections will be marked with a .

• 3: The selected fields will appear on the panel to the right with a . These are optional fields.

• 4: Fields with are required by The Joint Commission and must be completed.

• 5: Click when finished adjusting the layout.

• 6: Click to save the left-side layout for future reports.

NOTE: Nuance Surgical CAPD will anticipate your behavior based on your use. Drop-down selections, favorites, and narrative template creation will increase the efficiency of this tool. For example, if you manually enter the name of your assistant once, it will automatically appear in the drop-down when completing the next note.




Technique

There are two areas in the Technique section that are Required Fields: Findings and Procedure or Operative descriptions must be completed to E-Sign the report. Indications and Procedure descriptions in this section are ideal for creating custom templates.

• The procedure performed previously entered in the Report Builder, now shows in the “Technique” area by name. Content can be entered into these fields using the following methods:

o Typing

o Using a speech-to-text system (such as Dragon Medical One)

o Using the Surgical CAPD dictation in-app button if enabled

o Selecting from a previously saved description

A master description can be chosen from the procedure library and then edited to meet the provider’s specific needs and writing style.

• Click to view the previously saved technique descriptions. A drop-down menu with your options will appear.




Indications

This short paragraph, a couple of sentences, is very important as it provides the clinical necessity for the procedure being performed. It is also important to state any previous, related surgery on the same or different structure/wound, to document why the patient is being considered for surgery. This offers clues that coders use to support specific modifiers.

It may be ideal to start this narrative section with a standard template identifying key information documented earlier in the form builder.

1. Dictate or type the statement of indication into the free text field. 2. Identify specific items that may change from patient to patient such as Name, Age, Sex, Preoperative

Diagnosis, and pronoun.

Create variables by using the Add Variable button (Shift+2). Content used to schedule the encounter and information previously entered in Diagnoses and Procedures can be searched and added as variables. Once referenceable variables have been added to the template, patient-specific information will pull in automatically regardless of encounter.

In this example the variables used are:

• Name

• Age

• Sex (Lower Case)

• Preoperative Diagnosis




Saving the variables which are now in blue as part of the template will pull this information.

Click “Save New” to name and save this Indication for future reports.

After saving, the button to the far right will now show the name of the most recently created indication. The drop-down associated with the button will show other templates.

Technique: Procedure Description

The procedures selected previously in the Diagnoses and Procedures now appear in the Technique section with the titled procedure and a corresponding free text field. There must be a Procedure defined in the Diagnoses and Procedures section for the Procedure to show in Techniques. If multiple procedures are performed, the system will generate a text box for each procedure. Providers can choose to document all in one place or in the separate text boxes that are available.

As in the previous free text area for Indications, providers can enter text using a variety of methods. It is a frequent request to simply type or use a voice-to-text solution instead of creating a template. The request is common for short procedures and from those providers who want to ensure there is variance in the narrative sections of the note, which is a CMS (Center for Medicaid/Medicare Services) recommendation. Providers may express concern with the additional clicks that may be required to edit a template.

In addition to creating content on their own and clicking to save a custom template, providers also have the option to select from the Master Library of templates and edit to fit their need by clicking Choose Description.

After clicking the Choose Description button a drop-down will display.

• My Descriptions – Custom Templates Created by the Provider

• Master Descriptions – Generated by the selected procedure

• Choose From Library – A listing of all available narratives




Selecting the “Choose From Library” reveals the following menu with the following options:

- Descriptions for This Procedure defined previously in the report.

- My Descriptions which have been created by the provider as templates

- All Descriptions is all available descriptions for all procedures in the library

Select “All Descriptions” to reveal the full library.

Search the Master Description database by entering the name of the procedure in the search window.

Selecting the “Use” button at the end of a description will place it in the free text window.

Editing and Saving of the Procedure Description are done in the same manner as an Indication. The ability to

add and create new variables often comes in handy.

The sample below contains items that may need to be customized based on the outcome.

A Custom Variable can be used to better define: 3-0 silk ties. Highlight “3-0” and click the “Add Variable”

button and then select “Create New Variable”.




Title the New Variable

Create answers that will appear as a drop-down menu

The newly created variable appears in Pink. Pink is an indication there is a selection to be made. If no

selection is made the content contained in the variable will not appear in the final report.

Click on the new variable to display and select the desired option.

Select “Next” to move to the next Custom Variable.

Select the green checkmark to enter the selection into the report. If there are multiple variable

fields within the description, clicking the “Next” icon will move to the next variable to be addressed.

After a selection is made the variable turns blue indicating the content will appear in the final report.




Risk Factors

Risk Factors is an optional section that can be completed to obtain a more detailed picture of the patient. It is possible that these can be imported from the EHR in some instances; but, not in most cases. It is also important to be aware that Surgeons in Outpatient Surgery Centers may document to maintain or enhance

their MIPS (Merit-based Incentive Payment System) Score Card. The recommendation is to document all Risk Factors such as chronic illnesses and previous surgeries which may pose a risk to the outcome of the current procedure. This information may also be contained in the Medical Record and deemed as an unnecessary step.

The file icon is used to change the view of available Risk Factors.

Clinical Height and Weight may be included as part of the admission and scheduling interface providing pre-populated data for the calculation of BMI.

BMI calculation data can be entered manually or imported as Metric or Standard (Imperial) and a Custom BMI calculates automatically.

Custom BMI data can be entered alone without supporting data.

NOTE: BMI when above threshold is frequently coded with modifier .22 Increased Procedural Services. This

code adjustment can be made from the Charge Capture screen. This type of adjustment is not limited to BMI.

The reimbursement value of Increased Procedural Services can be as high as 30% increase procedure value.




Associated Providers

Associated Providers, such as Attending, Admitting, Primary Care, etc., are not required. Associated provider names can be entered or selected manually and, in some cases, can be prepopulated with a direct outward feed from the EHR or scheduling interface (SIU).

To Send or Carbon Copy (CC) your report to other providers:

• Look up the provider’s name in the Report Distribution section

• Click “New Recipient” if the required recipient is not found

• Enter the provider’s name and fax number

NOTE: Nuance Surgical CAPD has the capability to auto-fax reports to your office. Find out more by going to the “Auto-Faxing” section of this guide.

Charge Capture (Suggested)

If diagnoses and procedures are selected from Surgical CAPD’s prepopulated choices, suggested ICD-10 and CPT codes will auto-populate in the Charge Capture section. This documentation is available for faxing and can be preset to transmit when signing the note.

NOTE: You can edit the suggested codes by clicking on the section. For CPT codes, you can select the “Add modifiers” button to add modifiers. (ex. bilateral procedure).




Report Preview

Go to the Report Preview section to review the report before E-Signing.

To edit any field within this section:

• Select the field that needs to be changed

• Make any necessary changes

• Click to exit out of the field

NOTE: Blank fields will not show up on your final, signed report. They appear on the Report Preview so you can easily click on the field and add any additional information.




Saving the Report

Reports are not saved automatically. You must take one of the following actions to save.

• Work in Progress: Saves the report within Surgical CAPD so you can come back and finish it later.

• Approval Pending: Mid-levels can sign the report as “Approval Pending” if they need an additional signature on the report. This should not be used without a midlevel process in place as it adds additional signatures and attestations to the document.

• E-Sign: Finalizes the report and places an electronic signature on it. The finalized document should appear in the EHR shortly after e-sign.

NOTE: Any of these actions will save the report. These options are also available under at the top of the screen. If you do not see the “E-Sign” button, go back, and complete the fields that still have red triangles.




Additional Report Actions




Custom Descriptions and Reports Nuance Surgical CAPD enables you to create both Custom Descriptions and Custom Reports.

• Custom Descriptions are saved within the Technique section and are linked to the procedure.

• Custom Reports (commonly referred to as Custom Report Templates) are located at the top left corner of your report. You can access them by clicking the report type.

• With Custom Reports, you can save more than just the Field descriptions such as Assistances, Pre-Operative Diagnoses, etc. This saves the report in its entirety.

Creating a New Custom Description

• Select the procedure you would like to document under the “Diagnoses and Procedures” section.

o Multiple procedures create multiple designated text areas in Techniques for each procedure.

• Each procedure added to the report will have a Technique section associated with it. Enter the procedure description that you would like to save.

• Click to save this new procedure description.

• Click if you made changes to an existing description to save the updates for future use.

NOTE: If there are multiple procedures entered, it is acceptable to document all procedures within the primary procedure window, leaving the others empty. The empty window will display a yellow triangle.




Using a Custom Description

Click to use a previously saved technique/description from the available list of descriptions.

NOTE: If you have a previously saved description, it will appear as it does below:

• My Descriptions: View any saved procedure descriptions for the current procedure.

• Master Descriptions: These are procedure descriptions that Nuance has provided as a starting point.

• Choose From Library: If you are unable to find a custom description under “My Descriptions” or “Master Descriptions,” this option will show all available descriptions for the selected procedure.

• Clear Description: Clears everything from the Technique text box.

NOTE: Many organizations choose the profile setting: “Auto Populate Custom Descriptions” based on the procedure selected. This can be undesirable to some providers. This can be turned off from the profile setting by the local admin.




• Descriptions for This Procedure: View all Nuance Surgical CAPD users’ descriptions for the selected procedure.

• My Descriptions: View all your previously saved descriptions.

• All Descriptions: View all descriptions within the Nuance Surgical CAPD library.

• Click to pull the description into the report for editing.

• To search for a customer description, use the search function at the top of the page.

• Save the description for future use by clicking “Save New” and renaming it.




Creating a New Custom Report

If you document a procedure often, it is advised to save it as a Custom Report, which will save the report in its entirety and make your documentation easier. A question that can be asked after completing a report and before E-Sign is “Is this report typical of this type of surgery?” and “Would you like to save this as a Custom Report with all of the selections in Diagnoses and Procedure and General Information retained?”

• Fill in all the fields you wish to be saved in your Custom Report.

• Click at the top of the left-hand panel.

• Click .

• Enter a name for the report and click .

NOTE: Your list will grow as you begin to build your Custom Report library. (delete this – it is obvious. Screenshot directly above was added)




Master custom reports are also able to be populated in your account. These are standard reports Surgical CAPD has created as a starting place for new providers. Four specialties are supported today: ENT, Urology, General Surgery, and Orthopedics. See the example below:




Using a Custom Report

• Click at the top of the left-hand panel and a list of Custom Reports will appear.

• Click “OK” once you have selected a Custom Report from the list and the information will populate the report.

• You will be taken to the Report Preview page where you can make edits.

• Click to edit the name of the Custom Report.

• Click to save the template for future use.

NOTE: If you wish to use a Custom Report, remember to select it at the very beginning as it will overwrite and clear all data entered in the report.

Creating and Using Variables Variables will pull in patient-specific information or information that has been previously documented throughout the report into the Indications or Procedure Description fields in the Technique section.

• Place your cursor where you would like the variable to appear.

• Click or press Shift+2 to get a list of available variables.

• Select the desired variable and the information will be inserted in the text section.




• To create a new custom variable, click and complete the fields, placing each new answer on a separate line

• Click .

• Variables will appear in the report with blue or red shading.

o Blue variables are complete, and no additional action is required.

o Click on the Red variable to see potential answers. After selecting an answer, the field will turn blue.

• If there are multiple custom variables throughout a description, select the first variable and then click “Next” to jump to the next variable. You can edit a custom variable by selecting “Edit Variable” from this screen.

NOTE: If a variable is pulling in patient demographics or information from the note, it will be blue, and you cannot edit it. Custom variables can be edited but cannot be deleted. If using a speech-to-text product, your solution’s delimiters and variables can be used in most cases.




Creating Custom Reports from Transcription Templates An admin can create a Custom Report from transcription templates and other documents and provide ease of use and improve adoption by reducing obstacles. Be certain to follow HIPAA compliance rules ensuring that all personal medical and financial information is not contained and source documentation.

The purpose of creating a Custom Report prior to provider training and Go-Live is to demonstrate the benefits of using Custom Report, ease of use and speed, in addition to real-time documentation reducing issues of compliance and the additional documentation associated with transcription and the necessity of an immediate post-operative note. It is understood that a Custom Report in Surgical CAPD is owned by the provider and must be viewed, finalized, and completed by the provider.

Documentation received for the creation of Custom Reports often lack information required by SCAPD. Ideally, source documentation will have the following:

• Surgeon Name and Specialty

• Pre-Operative Diagnosis

• Post-Operative Diagnosis

• Procedure Preformed

o Procedure Description

• Assistants

• Blood Loss

• Specimen Removed

• Anesthesia

It is common to receive only the following:

• Surgeon Name

• Procedure Preformed

o Procedure Description

• Anesthesia

It is important to move forward and create a Custom Report using only the available information provided and tools which can create definition. Familiarity and use of web based and internal ICD-10 resource can be used to greater define items such as procedure performed. If you have access to the medical record where a previous operative report exists as it may assist to define details within the narrative description.




Source Document Example

In the example below all that is provided is the procedure performed, and description. There are opportunities for variables and custom variables which can create the needed variations often desired in the narrative sections of an operative report.

Procedure: Achilles’ tendon lengthening

After informed consent was obtained, the patient was brought to the operating room and placed in the supine position on the operating room table. After satisfactory general anesthesia was administered, the _____leg was prepped with ChloraPrep and then draped out in the usual sterile fashion. After exsanguination of the leg, the tourniquet around the thigh was inflated to 350 mmHg.

A time-out procedure was performed to identify the correct patient, procedure, and the side of the procedure.

To access the posterior aspect of the _____leg a bump was placed underneath the _____buttock. A longitudinal incision was made just to the medial side of the midline medial to the previous incision. Once through the skin and subcutaneous tissue the Achilles tendon was identified. It was somewhat scarred into the skin posteriorly and this was carefully sharply dissected off preserving the vascularity to the skin. The entire tendon was then exposed distally. An incision was made in the coronal plane in the tendon. The tendon was then divided proximally on the anterior aspect and distally on the posterior aspect. This allowed me to then dorsiflex the ankle about 10-degrees past neutral. This allowed the tendon to lengthen by about 2 cm. After thorough irrigation and hemostasis, the tendon was repaired with a Vicryl suture in a running fashion. I had a good area of tendon apposition with good repair.

The incision was then closed with Vicryl and Nylon. The incisional area was infiltrated with 0.5% Marcaine with epinephrine. A sterile dressing was applied. The tourniquet was deflated.

He She was awakened and taken to the recovery room in stable condition. There were no complications.

• Access Surgical CAPD using your Nurse of Admin role

• Use “Create New” to being your report

• Select the Provider by Name

o Define the report type

o No patient information is needed

• Begin your Custom Report by defining the procedure performed

o Entering Achilles’ tendon lengthening displays the following options to choose.

▪ Lengthening of leg tendon

▪ Lengthening of ankle tendon

▪ Ankle arthrotomy

o If unfamiliar with the Achilles tendon a simple internet search will let you know this is option ii, Lengthening of the ankle tendon




o Once the procedure performed is selected additional specificity questions appear in the dropdown

▪ Side or Laterality

▪ Tendons

▪ Notes

o As a rule, I make no specificity selections for the provider. Leave this for the provider to decide what should be completed in advance or if more that one report should be created based on laterality.

• Post and Pre-Operative Diagnosis can be addressed if you wish

o Because the Procedure Preformed has been entered there are now additional selections in the dropdown for Pre-Operative and Post-Operative Diagnosis

▪ “Related To: xyz (procedure name)

o You may wish to make sections of a few common diagnosis, or you can leave this for the provider to complete. Removing addition or inappropriate diagnosis can be removed easily.

• Complete the custom report following the steps detailed in the previous section titled “Create a New Custom Report”. After “Create New Custom Report” has been selected, select the provide name and save. Selecting “Save for Me” will save the report under the name of the person creating the report and not the provider.




Addendum of Report After E-Signing a report, it will lock based on the time frame set by your facility, which could be anywhere from immediately after E-Signing to days after. You will know when your report is locked by the lock icon that appears below the green check. If the report is locked, you can addend the report.

• Search for the correct document and click .

• A text box labeled “Make Addendum” will appear. Enter the changes that are needed.

• Click to finalize the document with the new addendum or .




NOTE: If you need to make a change on a locked report that requires editing the actual report, contact your facility’s Surgical CAPD Medical Record Administrator. Only an onsite administrator can unlock the report. Please do NOT enter “Report needs to be unlocked or canceled” in the Addend text box. This will prevent any other action from being taken on the report and you will have to create a new report.

Changing the Patient on the Report If you begin a report and realize you are documenting on the wrong patient, you can easily change the patient if the report is not locked.

NOTE: You can change the Date of Encounter through this same process. Report types cannot be changed. If you have begun a specific report type and it is not the correct one, a new report will need to be created.

Change when Creating the Report

• Click the patient demographics section on the left-hand panel.

• Click “Search Patients.”

• Search for the patient by name or account number.

• Select the correct patient and click “OK.”




• If you are unable to find the patient under “Search Patients,” click “Manual Patient” and manually add the patient’s name, medical record number, account number, date of birth, and gender.

• Click “OK”.

Changing Patient Information from the Launchpad for reports “Saved as Work in Progress.”

• From the Launchpad, go to “Reports.”

• Select the correct patient sticker and click .

• Click “Edit Patient Information.”

• Search for your patient in the search box and click .




• If you cannot find your patient on the “Search Patients” tab, click on the “Enter Manually” tab, enter

the details for the patient, and click when finished.

NOTE: Based on your facility settings, you may be required to provide a reason for changing the patient.

NOTE: Commonly, reports are locked immediately upon E-Signing and would require an Addendum in most cases. The local administrator will need to address any issues or site rules.

Admin Settings

Based on your role, you may have access to certain sections underneath the tab on the Navigation bar. You may be able to create user accounts for people who need access to your reports, editing your fax listing, or view patient instructions.

Create a User Account

• Click on the Navigation bar.

• Click and complete the fields.




• Click to save.

Modify an Existing User

• Click “Edit User.”

• Fill out all necessary fields (mandatory fields are noted by *).

• Click “Update User” to save.

Create/Modify a Fax Listing

• Click “Create New Fax Listing” or “Edit Fax Listing.”


• Click “Create New Fax Listing” or “Update Fax Listing” to save.

Create/Modify Patient Instructions

• Click “Create New Patient Instructions” or “Edit Patient Instructions.”


• Click “Create New Patient Instructions” or “Update Patient Instructions” to save.




Customizing Account Settings

Auto-Faxing

You can set up auto-faxing and automatically send a copy of each signed report to your office, billers, or anyone else who needs to see the final operative report.

• Click on your name in the top right corner and select “My Settings.”

• Go to the section labeled Report Distribution and fill out the First Name, Last Name, and Fax sections.

• Click and then .

NOTE: Automatic report distribution of the Charge Capture Report can also be set up in this section. The Fax Number must be ten digits (xxx-xxx-xxxx).

NOTE: A local admin is also able to set the fax distribution list for you.




Updating Passwords and Account Information


• Edit the account information as needed in the Personal Information section and click to save.

• Click to close your account settings.




Surgical Case Log

Surgical CAPD collects data from your reports that you can access within your settings. This data can be used to help you apply for or maintain credentials and registries.


• Scroll down to the Surgical Case Log section, select your date range, and click .

• This will download an Excel file with all your records for the selected dates.




Surgical CAPD Mobile Application Overview

• The Navigation bar will appear at the bottom of the screen.

o Select “Schedule” to search and select a patient from your list.

o Select “Notifications” to see reports that are saved as Work in Progress, Approval Pending, or past the scheduled date of the procedure.

o Select “Patients” to search for a specific patient for whom you would like to begin a report.

o Select “My Reports” to view all your reports in Surgical CAPD.

• You can create a report, E-Sign, and fax reports using the mobile application.

• Reference the current Surgical CAPD User Guide or Quick Reference for additional information.




Surgical CAPD Mobile Application Workflow

Log into the Surgical CAPD App using the same credentials as the desktop application.

Dragon Medical Embedded (DMe) Andriod

Select a patient from the scheduled list.

Select Begin

Complete required elements.

Use the device keypad to add text in any text field.




Navigate to the field where text is to be entered.

Tap the textbox to display the DMe toobar

Select the blue DMe dragon flame icon to open the Speech to Text window

As soon as the Window is open, the microphone is active or live

Immediately begin speaking

Be sure to include punctuation such as periods and commas

When the entry is complete say “Microphone Off” or

tap the green microphone icon to stop recording.

Text transtions to the textbox when the recoding stops.

Complete your report and e-sign as you would in the desktop application.




Dragon Medical Embedded (DMe) Apple iOS

Select a patient from the scheduled list.

Select Begin Report

Complete the requirements of the report

Use the device keypad to add text in any text field.




Navigate to where text is to be entered.

Tap the textbox to display the DMe toobar with keypad

Select the blue dragon flame icon in the upper right corner of the DMe toobar with keypad

As soon as the Window is open, the microphone is active or live

Immediately begin speaking

Be sure to include punctuation such as periods and commas

When the entry is complete say “Microphone Off” or

tap the green microphone icon to stop recording.




A tap of the green microphone icon changes the status to Standby Mode. This allows the user to pause the recoding and then begin again by saying “Wake Up” or tapping the blue microphone icon.

Say “Microphone off” to turn off microphone and delivers text to the textbox.

Complete your report and e-sign.

Users can Enable or Disable Standby/Wake Word funcitionality by selecting the file icon on the far right side of the DMe toolbar.

The What You Can Say menu opens

Select “Options” from the menu

Choose to enable or disable Wake Word




Adding Images The Surgical CAPD app allows you to take pictures during your cases and attach them to your report. It is HIPAA compliant as the photos are saved to the Surgical CAPD mobile app and not to your photos. You can also upload a picture from your desktop.

Mobile App

• Log in to the mobile app

• Find your patient

• Select the camera in the top right corner

• Click “Take a Photo”

Desktop

• Enter the report to which you want the image attached

• Click on the top right corner of the report

• Click “Upload Images” from the drop-down

• Click “Add Selected”




• Your image will appear under “Procedure Images” in the report.

Launchpad

• Click on the appropriate patient sticker

• Click “Images”

• Click “Upload Images”

NOTE: There are organization where there are cameras installed in the Operating Room and other Surgery areas. Images may populate to the chart automatically. There may be an opportunity to navigate to a secure network folder to pull images into the note in SCAPD. Refer to local administration and IT/IS for details and potential.

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