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

1. Computer Assisted Physician
Documentation (CAPD): An Insight
Presenter - Marsha S. DiamondFollow us :
Know the Pros and Cons of a CAPD System

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
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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
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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
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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
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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
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7. Improves Accuracy
Addressing documentation deficiencies real-time
means reduced additional time spent later addressing
deficiencies
 Increases coder accuracy
 Increases provider’s accuracy
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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
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9. To see the complete presentation check the below
link:
http://www.audioeducator.com/hospitals-and-health-systems/capd-
implementation-02-05-14.html