Smart Surgery

3 Ways Tech Alleviates the Surgical Documentation Headache

13 Dec 2018

American hospitals are struggling. In addition the the rising cost of healthcare globally, US hospitals continue to pour money into the system and get less out of it. According to a study by the Commonwealth Fund, the US ranked last among eleven developed nations in their provision of medical care.

Technology offers an opportunity to change that, especially for surgery departments. Embedded surgical checklists, workflow automation tools, risk calculators, and many other assets are concrete examples of how surgical IT is helping to cut down on the hospital’s most costly outcomes and inefficiencies.

Check out how new approaches to documentation and reporting are makings waves in surgical care and hospital analytics:

Surgical Documentation

One of the largest burdens on global healthcare systems is administrative inefficiency. The US alone pays $750 Billion annually for expenses that are not directly tied to healthcare. Wasteful overhead is both expensive and eats away at a hospital’s ability to provide quality care.

In the OR, where the hospitals draw their largest source of revenue, documentation and reporting is particularly time-consuming, slows down surgical workflow, and increases the risk of practitioner burnout and clinical error. Increasing the length of the procedure also increases the likelihood of complications. Under a value-based system, this further eats into the bottomline.

New solutions are helping to tackle both problems at once. Surgical checklists are one approach that’s shown significant success. In a study of South Carolina hospitals, those who utilized the World Health Organization’s Surgical Safety Guidelines saw a 22% decrease in mortality as a result of post-operative complications.

Adherence to these checklists can be problematic, however. Through digitally embedding them into the workflow and exploring ways for them to more directly assist the surgical team, hospitals can successful integrate these within the workflow. These checklists often require that important steps along the surgical procedure be marked. Through digitalization, it is now possible to denote these steps through voice and gesture control, making it easier than ever to document the events going on in the OR.

Reports and Risk Score

Surgical checklists have obvious benefits for the surgical team. But beyond helping to assist in the augmenting surgical workflow, these checklists also have another benefit: Standardization. Through creating a process that the surgical team uses to document all of the events in the OR, they are able to create comparable data. Rather than having information that varies in form, digital reporting helps to make guarantee that the data points are recorded in the same manner.

As AI and machine learning continue to become more prevalent in healthcare, this will only grow in importance. Standardized data saves time because it does not need to be scrubbed and organized prior to being used. Surgical reporting is valuable to hospitals. Being able to analyze the care across a series of parameters-- by procedure, by patient demographics, by surgeon-- helps to more acutely identify barriers that impact patient care. The next generation of healthcare will also utilize predictive and preventative care. As hospitals gather large amounts of data, the ultimate goal is to identify which patients are at highest risk for complications and to provide preventative care that avoids the illness all together.

Big Data and Data Protection

Surgical reports and risks scores don’t rely on information from a single individual, however. Rather, they depend on aggregate data from multiple patients. When collecting and processing patient information, it’s vital to think both about the potential and pitfalls that exist. Machine learning and AI are transforming the field of healthcare. They can predict cancer and read x-rays. But in order for these tools to be useful, they require large data sets, either from hospital systems’ private medical records or from large-scale public data sets. This raises serious concerns around how to best protect patient information. Compliance with GDPR and HIPAA is paramount, particularly as the fines for noncompliance are steep.


From assisting in managing individual patient care, to help standardize hospital-wide reporting, to large-scale healthcare analytics, reporting and documentation will remain one of the most important tasks in the hospital. With mounting healthcare costs, finding new and innovative ways to help reduce the cost and administrative burden will be crucial. Once effective methods are in place, though, hospitals are well-positioned to take on the next generation in healthcare.


Interested in learning more about surgical reporting and documentation? Caresyntax is building applications to automate data collection, saving hosptials time and money. To learn more about our surgical reporting and analytics platform, or any of our data-enabled technologies, click here!

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Sean Witry

Written by Sean Witry

Sean Witry works as Community Manager and Content Marketer at caresyntax. With a background in international affairs and a focus in public health, he's passionate about exploring technology's role in increasing access to quality care and improving patient outcomes. You can reach him on LinkedIn or via email at

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