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Computer Assisted Physician Documentation - Pros and Cons of a CAPD System


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Computer Assisted Physician Documentation – Get the tips for selecting an effective CAPD system for your group in this informative session.

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Computer Assisted Physician Documentation - Pros and Cons of a CAPD System

  1. 1. Computer Assisted Physician Documentation (CAPD): An Insight Presenter - Marsha S. DiamondFollow us : Know the Pros and Cons of a CAPD System
  2. 2. What is CAPD (C)omputer (A)ssisted (P)hysician (D)ocumentation Computerized tools to automate physician documentation and provide the necessary clinical information as well as reimbursement information CAPD systems enable the provider to utilize dictation to document the encounter and prompt for more specific information when required for documentation and/or reimbursement purposes 2
  3. 3. EXAMPLE OF CAPD Technology Case Scenario Patient presents to ED with acute episode of asthma. Provider dictates “acute asthma exacerbation” Would be appropriate for ICD-9, however, ICD-10 needs severity of the asthma: - mild intermittent - mild - moderate - severe persistent 3
  4. 4. EXAMPLE OF CAPD Technology (continued) CAPD Technology will:  Detect missing or incomplete information  Detect unclear associations between relevant findings and unspecified diagnosis (es)  System will: - query the physician while dictating to add the severity - allow provider to select correct information 4
  5. 5. CAPD Advantages  Aids in clinical documentation improvement  Increases accuracy  Increases speed of completion  Decreases physician/coder time  Better patient care  Can be integrated into existing clinical documentation improvement programs 5
  6. 6. Clinical Documentation Improvement Real-time “prompts” Through the use of clinical language understanding (CLU) technology, the system has the capability of interpreting dictation as well as other documentation in the encounter and determining if clarification/additional documentation is needed and “prompts” dictator for needed information 6
  7. 7. Improves Accuracy Addressing documentation deficiencies real-time means reduced additional time spent later addressing deficiencies  Increases coder accuracy  Increases provider’s accuracy 7
  8. 8. Increases Speed of Completion  No query process time necessary  No time spent by coder identifying query is necessary, writing query and awaiting results of query before coding/billing can take place 8
  9. 9. To see the complete presentation check the below link: implementation-02-05-14.html