Accurate and legible documentation is essential for ASCs to improve their quality of care and revenue. Here are the solutions to improve ASC documentation.

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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.
 Preoperative and postoperative diagnosis
 Title of procedure
 Surgeon, co-surgeon and/or assistant surgeon
 Anesthetic and anesthesiologist
 Summary of procedure
 Complications and unusual services
 Immediate postoperative condition
 Estimate of blood loss and replacement
 Fluids given and invasive tubes, drains and catheters used
 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
 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.
 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.
 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