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Surgical Computer-Assisted Physician Documentation


Nuance Surgical CAPD

Nuance Surgical Computer-Assisted Physician Documentation (CAPD) is a real-time, in-workflow solution that streamlines operative report and procedure note documentation to improve surgical documentation quality and reimbursement.

Nuance Surgical CAPD enables surgeons to create a complete, fully compliant operative note, eliminating transcription and disruptive coding queries and accelerating the revenue cycle. The solution guides surgeons through the documentation process by providing critical data and automatic prompts when clarifications are needed to capture the required level of specificity, so surgeons can quickly document pre- and post-operative notes correctly the first time.

Use Cases

  • Nuance Surgical CAPD gives surgeons integrated, rule-based workflows designed to capture the appropriate diagnostic and procedural specificity necessary for appropriate care and reimbursement.
  • When a patient encounter takes place, whether bedside or in a procedure room, Nuance Surgical CAPD captures all required patient information to generate clinical documentation and charge data in one pass.

Supported Devices

  • Desktop
  • Tablet
  • SmartPhone

Version Details

Compatible with Cerner Powerchart

Key Features

Intuitive Surgical Workflows

Nuance Surgical CAPD offers integrated workflows that have been designed to flow the way surgeons have documented for years, making physician adoption more natural. Real-time advice helps surgeons add specificity to procedure and diagnosis documentation as they are creating notes to ensure appropriate reimbursement and reflect patient acuity.

Predictive, adaptive user experience

Surgical documentation rules are constantly evolving. Nuance Surgical CAPD offers a personalized user experience by learning and adapting to each individual physician’s practice behavior as well as the evolving rules of clinical and surgical documentation.

Secure Image Capture

Securely capture HIPAA-compliant images using your mobile device and attach them to your documentation to better articulate conditions and/or procedures.

Automatic report distribution and case logging

Eliminate the need for manual track charges by making compliant clinical documentation and charge data immediately available to Cerner, care teams, and coding department, while logging data for research, recertification, and analytical purposes.