Procedure documentation software records what a doctor did and found during a procedure, such as an endoscopy, and the anaesthesia given during it. An endoscopy is a test in which a doctor passes a thin tube with a camera into the body, for example into the stomach or the large intestine. The software is a part of the patient's record. Products like this are sold mainly to hospitals and endoscopy centres in the United States.
Why is a procedure different from an ordinary visit? A visit leaves a short note. A procedure leaves a detailed report. The report must record the medicine used to sedate the patient, and the patient's heart rate and oxygen level throughout. It must record every finding, every sample taken and any problem, with photographs. It must produce the right medical codes, because a procedure is billed by exactly what was done. And it must record the quality measures on which doctors are judged.
Consider a colonoscopy at an endoscopy centre in Pennsylvania. A colonoscopy is an endoscopy of the large intestine, done to find and remove polyps. A polyp is a small growth that can turn into cancer. The procedure was booked through operating room scheduling. During the procedure, the anaesthesia record takes the patient's heart rate, blood pressure and oxygen level from the patient monitor every five minutes, without anyone typing them in. The doctor finds two polyps, of 6 mm and 4 mm, and removes both. Instead of typing, the doctor picks each finding from a list on the screen: its place, its size and how it was removed. The doctor attaches photographs taken by the camera.
Within three minutes of finishing, the software produces the report. It turns the picked findings into clear sentences. It suggests the codes for a colonoscopy with the removal of two polyps. It also records two quality measures. One is the withdrawal time: the time the doctor spent examining the intestine while pulling the camera out. Here it is 9 minutes, above the usual minimum of 6. The other is whether a polyp was found, which counts towards the doctor's adenoma detection rate. An adenoma is the kind of polyp that can become cancer. The polyps go to the lab, and the result is added to the report when it arrives.
Why pick findings from lists instead of writing freely? Because each picked finding is stored as data. The centre can then count, for instance, how many polyps each doctor found this year. Notes written freely are much harder to count, as explained in clinical NLP. The finished report is stored in the patient's ambulatory EHR, beside every other visit.