Postoperative surgical workflow software

Postoperative surgical workflow is as important and complicated as surgery scheduling. Our surgery scheduling software helps manage postop easily. See a demo.

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The postoperative surgical workflow includes the following:

  1. Surgery postoperative note by the surgeon.
  2. Postoperative orders by surgeon. This could include procedures, laboratory, diagnostics, medication, nutrition, postoperative followup appointments, transition of care referral order(s).
  3. Billing for the surgery procedure.

You can handle these manually, with a spreadsheet, or a surgical workflow management system.

postoperative surgical workflow software
Surgery scheduling software postoperative workflow

Surgical operative note

Writing an opnote is part art, part science.

As part of your postoperative surgical workflow your surgeon needs to update the following to ensure appropriate billing/reimbursement and for patient continuity of care. Higher levels of documentation specificity leads to lower billing headaches.

First and foremost you are going to need the planned vs performed procedure narrative. In other words, what procedure was planned based on preoperative diagnoses / findings and what was actually performed.

Keep in mind that your prior authorization was for a specific procedure and if the actual procedure differs from the authorized procedure, you are going to need this documentation during your postoperative surgical workflow for claims support.

postoperative surgical workflow software - procedure narrative
Surgery scheduling software procedure narrative

The note has at least a few sentences about “Indications for Surgery” that your coders can use.

You need to be able to document why the patient was brought to the OR. If there are any past surgeries related to this procedure, the operative note needs to document that.

This alone will dictate whether your coders will use modifier 58 (Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period) or modifier 78 (Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period).

Make sure that your surgeon’s operative note has “Complexity” section that buttresses your claim for any extra payment. This section is very important for coders to be able to use Modifier 22 (Increased Procedural Services).

In our postoperative surgical workflow software, you can use the notes section for this.

Procedure anesthesia narrative

Document which anesthesia was used (it might be different from what was originally ordered). You can also choose to record the agents / medications that were actually used.

postoperative surgical workflow software - anesthesia administered
Surgery scheduling software anesthesia administered

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    Complications

    Document any additional medical problems that developed following the surgical procedure. When you order follow up surgery procedures, documenting complications will help you support your reimbursement request.

    In our surgical scheduling software, you would document it like below.

    Surgery scheduling software postoperative complications
    Surgery scheduling software – postoperative complications

    Postoperative & preoperative diagnosis

    Make sure you document both preoperative and postoperative diagnosis. Payors like to see whether the diagnoses were the same before and after the surgery. This also helps you with your follow up orders.

    Keep in mind that the preoperative diagnosis is a surgeon’s opinion. The diagnosis is confirmed during surgery.

    In our surgical scheduling software, you would document it like below.

    Surgery scheduling software postoperative diagnosis
    Surgery scheduling software postoperative diagnosis

    Procedure estimated blood loss

    All surgery postoperative notes will contain this section. As part of your postoperative surgical workflow , your surgeon should document the estimated blood loss is the approximate amount of blood that the patient lost during the procedure or surgery.

    You can record this in a quantitative amount, e.g., 500 milliliters, or simply use free text like “Minimal”, “None” etc.

    In our surgical scheduling software, you would document it like below.

    Surgery scheduling software postoperative estimated blood loss
    Surgery scheduling software postoperative estimated blood loss

    Procedure findings

    Did you have any clinically significant observations that you confirmed during the procedure? Did you/the surgeon discover any new clinically significant findings during the procedure? If so, those are to be recorded in the surgery postoperative note.

    In our surgical scheduling software, you would document it like below (separate from the preoperative + postoperative diagnosis)

    postoperative surgical workflow software -  postoperative findings
    Surgery scheduling software postoperative findings

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      Postoperative surgical workflow – specimens

      If any specimens were collected during the procedure, those should be duly noted in the surgery postoperative note. These can include tissues, objects, or samples taken from the patient etc.

      This allows your staff to place follow up pathological analysis orders. As part of the postoperative surgical workflow, they need to remember to place this order). This also assists your billers/coders for future billing.

      In our surgical scheduling software, you would document it like below.

      Surgery scheduling software postoperative specimens
      Surgery scheduling software postoperative specimens

      postoperative surgical workflow – Procedure Narrative

      As a surgeon, you are required to record procedure narrative as part of your surgery postoperative note. As most surgery billers/coders will tell you, the more descriptive you are in the notes, the more helpful it is for billing purposes.

      Your procedure narrative could/should include descriptions of the procedure. It is very helpful for billers when it includes extensive details of procedure site preparation, measurements and markings details, procedure times, instrumentation, and vital signs and other monitoring data.

      postoperative surgical workflow software - procedure narrative
      Surgery scheduling software postoperative narrative

      Procedure implants and drains

      Any materials placed during a procedure are required to be documented in the surgery postoperative implants narrative section. These can/shall include stents, tubes, and drains.

      In our surgical scheduling software, you would document it like below.

      Surgery scheduling software postoperative implants
      Surgery scheduling software postoperative implants

      Surgical operation note fluids narrative

      This is an optional section where you record the amount of fluids administered during the surgical procedure. We allow for entering this information as it can be made a part of the surgery postoperative note.

      Surgery scheduling software postop fluids
      Surgery scheduling software postop fluids

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        Plan of care note

        The discharge plan of care note contains ongoing care information for the patient. This is important because of the general disconnect between surgeons and clinical/non-clinical staff in their practice.

        This section could/should include postoperative orders, interventions, encounters, services, and procedures for the patient.

        Using this section helps office staff prepare follow up procedure/imaging/laboratory orders and also helps with clinical reminders.

        Surgery scheduling software discharge plan of care
        Surgery scheduling software discharge plan of care

        Postoperative surgical workflow – followup appointments

        In our surgical scheduling software, you would document it like below. The software handles following tasks for you.

        1. Place surgery post-operative appointment request order
        2. Update surgery post-operative appointment request order with appointment date
        3. Notify patient about surgery post-operative appointment date
        4. Send patient reminders about surgery post-operative appointment
        Surgery scheduling software postoperative followup appts
        Surgery scheduling software postoperative followup appts

        Postoperative surgical workflow – Nutrition

        Often you / your surgeon will place postoperative nutrition / diet orders. These can be oral diets, supplements or even enteral formulae, as deemed needed by the surgeon.

        Using our surgery scheduling software you can manage these postoperative nutrition / diet orders with ease (see below).

        The related tasks that you have to handle for these diet orders are as follows – the software handles reminders on your behalf as well.

        1. Notify patient about post-operative nutrition instructions 
        2. Remind patient about post-operative nutrition instructions adherence 
        postoperative surgical workflow software - nutrition
        Surgery scheduling software postoperative nutrition

        Postoperative surgical workflow – Medication orders

        In your postoperative / discharge plan of care, you would be prescribing various medications. If you enter all such details in your narrative, your staff can thereafter follow up with the requisite medication orders.

        In our software, you can also choose to prescribe medications as you did/do for the preoperative stage. Alternatively, your surgical coordinator can place those orders for you as well.

        Our surgical scheduling software will handle the following tasks for your staff.

        1. Send fax for post-operative medication order pre-certification
        2. Update post-operative medication order with pre-certification proof
        3. Notify patient about pre-certification approval status
        4. Send fax for post-operative medication order prior authorization
        5. Update post-operative medication order with prior authorization proof
        6. Send fax for medication order
        7. Notify patient about prior authorization approval status and RX order
        8. Ask patient about RX fill status 
        9. Update medication order with RX fill status
        10. Send patient reminders about post-operative medications adherence
        Surgery scheduling software postop medications
        Surgery scheduling software postoperative medications

        Postoperative surgical workflow – Transition of care

        Whether you are transitioning the care of your patient to another provider, or if you need a consult with another specialist / provider, you would need to place such referral orders with your staff.

        In our surgical scheduling software, you would document it like below. The software handles following tasks for you.

        1. Update transition of care appointment request order with appointment date
        2. Notify patient about transition of care referral appointment date
        3. Send patient reminders about transition of care referral appointment
        4. Send fax for transition of care consult note
        5. Update transition of care request order with visit note results
        postoperative surgical workflow software - referrals
        Surgery scheduling software postoperative referral

        Document the surgery team

        Make sure you document the surgeon, co-surgeon (if any), assistant surgeon, assistant at surgery.

        Keep in mind the following:

        • An assistant surgeon and surgery assistant bills their work but are not responsible for pre / post operative care, nor do they document an operative note.
        • A co-surgeon bills their work but is responsible for pre / post operative care, documenting an operative note for their part of the surgery. So, in this case, you will have more than 1 post operative note.

        In our surgical scheduling software, you would document it like below. The software handles following tasks for you.

        1. Update transition of care appointment request order with appointment date
        2. Notify patient about transition of care referral appointment date
        3. Send patient reminders about transition of care referral appointment
        4. Send fax for transition of care consult note
        5. Update transition of care request order with visit note results
        postoperative surgical workflow software - opnote surgery team
        Surgery Scheduling software – opnote surgery team

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