Skip to content




All times in Central Time.

8:30-9:20 a.m.

Event Type

Share This Session

Share on facebook
Share on twitter
Share on linkedin
Share on email
Share on whatsapp

From Procedure Notes to Operative Reports: Solving the Surgical Documentation Conundrum with Artificial Intelligence

Presented by: Nuance

As the CMS and payer mandates in 2020 are increasing the pressure on providers to deliver on a growing amount of administrative mandates, surgeons in the OR are challenged to keep up with the complex demands of documentation. Operative reports need to capture fully specified procedures and diagnoses in order to generate appropriate reimbursement as well as improve patient care and quality outcomes. Current existing surgical workflows are not providing the necessary logic to meet the requirements for specificity, and are instead resulting in time-consuming retrospective reviews.

To help busy surgeons save time in their workday, 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 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 capture, reimbursement, risk scores, and quality metrics.

In this session, audience members will get an overview of the clinical and regulatory factors driving the need for complete documentation, the challenges of current surgical documentation workflows, and how AI tools can complement clinical documentation capabilities to provide complete, accurate, and timely surgical documentation that meets all requirements.

  • Market / Regulatory Factors
  • Surgery Care Setting – DCH Health Systems/West Alabama Urology Associates
  • Surgical Clinical Documentation Improvement
    • AI-Powered Workflow Tools for Surgery
    • Outcomes
      • Improved surgeon satisfaction; higher EHR adoption
      • Streamline documentation process
      • Reduce financial risk; greater reimbursement payments
      • Speed up time to document/code efficiency
      • Higher quality measurement and reporting; compliance
      • Reduction in the number of claims denied

Learner Outcomes

After this session, attendees will be able to:

  • Identify the market and regulatory factors increasing the pressure on surgeons to deliver accurate, timely clinical documentation
  • Integrate AI documentation tools in the EHR to improve surgeon clinical workflow
  • Highlight a use from DCH Health Systems/West Alabama Urology Associates on the integration of the solution to improve documentation in operative reports


Lucian Newman
Healthcare, Nuance Birmingham, AL

Matthew Thom, MD, FACS
West Alabama Urology Associates Tuscaloosa, AL

Kenneth Kolenik
Clinical Documentation and Coding, Nuance Communication, Inc. Pittsburgh, PA
Play Video