Surgical CAPD

Primary total knee arthroplasty

OR-4412 · Rivera, Ana · Elena Vargas, MD

Documenting

Observability

Sign & file writes logs and an APM waterfall

Completeness 62% · synthetic demo data only, no real PHI

LLM observability

CAPD findings

Documentation gaps

Computer-assisted physician documentation checks before coding.

Laterality not stated in procedure line

required

CPT 27447 is laterality-sensitive. CAPD detected “left” in the consent and laterality field but not in the procedure statement.

Implant identifiers missing

reimbursement

UDI / catalog numbers are required for implant registry and appropriate device billing.

ASA class and anesthesia type omitted

quality

Quality reporting and anesthesia billing expect ASA and modality.

Retrieve this operative note

Security

Who can open this note

Treating surgeon vs billing.svc bulk read of FHIR Patients and CAPD notes.

Case facts

OR / room: OR 3

Start: 07:30

CPT hint: 27447

Laterality: left

MRN: SYN-104882