Improving Documentation for Ambulatory Surgical Centers (ASCs)

Improving Documentation for Ambulatory Surgical Centers Ambulatory Surgical Centers or ASCs face several challenges such as lower reimbursement, staff shortage, increased competition and greater scrutiny by CMS, third-party payers and regulatory authorities. They need to find out more effective ways to overcome these challenges and continue providing high quality care while reducing errors, improving outcomes, enhancing efficiency and cutting down costs.

As you know, everything begins with proper documentation. With complete, comprehensive and legible medical documentation, you can make available the necessary healthcare information at the right time and provide the best patient care.

How Can Documentation be Made Effective?

Collecting Preoperative Information

Documentation should begin when the office personnel contact the patient to discuss the preoperative session. The personnel should request the patient or family members to bring proper identification and all the current medications when coming

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for the office visit. This will help to document the patient’s demographic details, drug name and dosage amount correctly. It is also required to collect the information about the type of surgery the patient is coming for, on what side of the body the procedure will be performed and why the surgery is needed. The information thus collected must be documented within the patient’s record. The record must have history and physical examination report by the patient’s primary care physician. The physical must have been conducted and documented within 30 days of the surgical procedure or service and should be updated on the day of the procedure to confirm the information has remained intact. Confirmation or alternative information taken during this time should be documented appropriately within the patient’s record.

Operative Notes Operative notes are the integral part of ASC documentation. An operative note documents the steps involved in preoperative, intra-operative and postoperative sessions. Whatever be the specialty, you must make sure that the following details are documented in your surgical note.

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Preoperative and postoperative diagnosis

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Title of procedure

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Surgeon, co-surgeon and/or assistant surgeon

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Anesthetic and anesthesiologist

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Summary of procedure

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Complications and unusual services

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Immediate postoperative condition

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Estimate of blood loss and replacement

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Fluids given and invasive tubes, drains and catheters used

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Hardware or foreign bodies intentionally left in the operative site

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There should be definitive documentation. Full disclosure is recommended without any accompanying errors.

Proper Dictation

Timely dictation is very important for improving your documentation. Operative notes must be dictated right after the surgery and processed within 24 hours.

Surgeons should avoid offsite dictation owing to compliance issues. If operative reports indicate the name of surgeon’s clinic or hospital instead of the ASC where the procedure was performed, the location won’t match in the operative report and claim. Third-party payers, especially Medicare could take this as a fraudulent claim.

Why You Should Have an EMR

Recording the dictation right after the surgeons emerges from the operating room, transcribing them, sending back the transcription to surgeons for correction and formatting the document can be tedious and time-consuming. An electronic medical record (EMR) system streamlines the operative reporting process while ensuring the efficient use of your ASC staffs’ time. Here are the major benefits of having an EMR

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Enhance Profitability – The system provides easy and quick access to the statistics that allow you to better perform detailed costing and analysis, detect historical patterns, benchmark critical data and optimize scheduling of patients, surgeons, rooms, staff, equipment and anesthesia personnel to enhance profitability.

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Reduce Costs – Switching from paper-based to electronic based systems would eliminate the cost associated with purchasing paper, assembling and copying, storage and records retrieval. The electronic systems also reduce the time and effort of staff by eliminating manual tasks which would further reduce the cost.

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Increase OR Efficiency – An electronic medical record system captures images and other patient specific values from surgical and anesthesia monitors and integrates all information into the patient file. This will allow the surgical team to chart quickly and efficiently, which will significantly increase operating room (OR) efficiency.

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Improve Physician and Patient Satisfaction – An electronic system eliminates the need to carry cumbersome paper files and allows physicians to access their schedules and patient charts anywhere in real time. It will also help with checking drug interactions more effectively. In this way, EMR enhances patient safety and quality of care, which improves the patient’s experience in your ASC facility.

Overcome

Flaws

Inherent

in

EMR

through

EMR

Transcription/Integration

However, the use of EMR templates limits narrative documentation and there is a chance for copy and paste errors. Due to these disadvantages, it is better to adopt EMR transcription, in which transcriptionists transcribe your dictations and populate the transcribed data into relevant EMR fields. Efficient EMR transcription /integration

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services

include

integration

of

voice

capture,

transcription

workflow

and

incorporating documents into your EMR system. Providers can upload their audio files to the transcription firm, where transcriptionists transcribe the information into a MS Word document. After the transcripts are edited and proofread and the QA procedures are complete, they are imported into the provider’s EMR system. This procedure allows providers to follow their preferred dictation mode as before and also enjoy the benefits of an EMR system.

Contact MTS Transcription Services 8596 E. 101st Street, Suite H Tulsa, OK 74133 Main: (800) 670 2809 Fax: (877) 835-5442 E-mail: info@managedoutsource.com

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