Surgical CAPD

Laparoscopic cholecystectomy

OR-4418 · Chen, Marcus · Priya Nair, MD

In OR

Observability

Sign & file writes logs and an APM waterfall

Completeness 28% · synthetic demo data only, no real PHI

LLM observability

CAPD findings

Documentation gaps

Computer-assisted physician documentation checks before coding.

Intraoperative cholangiogram not addressed

reimbursement

If IOC was not performed, a brief statement prevents downcoding disputes.

Specimen findings incomplete

quality

Document stone burden and bile appearance for the path correlation.

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Who can open this note

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

Case facts

OR / room: OR 1

Start: 09:15

CPT hint: 47562

MRN: SYN-110204