AI Medical Scribe for
A pre-anesthetic assessment compresses a full risk evaluation into minutes. Medical Scribe documents the airway exam, the ASA reasoning, and the consent conversation while you evaluate the patient in front of you.
A real example of the documentation Medical Scribe generates for anesthesiologists — ready before your patient leaves the room.
58F scheduled for laparoscopic cholecystectomy for symptomatic cholelithiasis. Previous GA for hysterectomy complicated by significant PONV; no documented airway difficulty. Hypertension on amlodipine 5mg daily; GERD on pantoprazole 40mg. No anticoagulants. Allergy: penicillin (rash). Non-smoker. Exercise tolerance >4 METs — climbs two flights without dyspnea. No personal or family history of anesthetic complications.
BP 142/86, HR 74, SpO2 98% RA, BMI 31.2. Airway: Mallampati II, thyromental distance >6cm, full neck extension, good mouth opening, dentition intact. Chest clear; heart sounds dual, no murmurs. ECG: sinus rhythm.
Risks, benefits, and alternatives of general anesthesia discussed, including sore throat, dental injury, PONV, and rare serious complications. Patient's questions about postoperative nausea addressed given prior experience; verbal consent obtained.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
A full list of tomorrow's cases, each needing a documented history, airway assessment, risk classification, and plan — before the first patient rolls back.
If an outcome is ever questioned, the record of risks, benefits, and alternatives you discussed is what gets examined. A checkbox is not a conversation.
A loose tooth, a PONV history, a family whisper of malignant hyperthermia — details mentioned in passing at the bedside are easy to lose before you reach a workstation.
Real-time transcription that understands medical terminology and clinical context.
Recognizes terms, conditions, and procedures specific to your practice area.
Generate comprehensive clinical notes in minutes instead of hours.
Enterprise-grade encryption and security to protect sensitive data.
These aren't generic formats — they ship in the product today, structured around how you actually document.
Plus 280+ templates across every specialty — or build your own in minutes.
Most of an anesthesiologist’s documented conversations happen before the case: pre-assessment clinic consults, telehealth reviews of complex comorbidities, and day-of-surgery bedside evaluations. Medical Scribe records each encounter and drafts the pre-anesthetic note while you move to the next patient — so the list is documented before the list begins.
The built-in Anaesthetist’s Note structures the draft the way the specialty thinks: Subjective for anesthetic history, medications, allergies, and fasting; Objective for airway assessment, examination, and investigations; Assessment & Plan for ASA classification, the anesthetic technique and rationale, PONV prophylaxis, and postoperative planning — plus the consent discussion in Additional Notes.
Anesthesia claims turn on what was assessed and what was disclosed. Because the note is drafted from the actual encounter, your airway findings, risk reasoning, and consent conversation are recorded as they happened — never reconstructed from memory, never invented. You review and sign before anything enters the chart.
Yes. The consent conversation — risks explained, alternatives offered, questions answered — is captured in the Assessment & Plan and Additional Notes sections of the Anaesthetist's Note, reflecting only what was actually discussed with the patient.
Airway examination findings you verbalize — Mallampati class, thyromental distance, neck mobility, dentition — are documented in the Objective section exactly as stated. Medical Scribe never invents an examination finding.
Yes. With apps for iOS, Android, Web, Apple Watch, and Mac, it works in a scheduled pre-assessment clinic, a telehealth pre-op consult, or a same-day bedside review in the holding bay.
Medical Scribe is HIPAA compliant, with recordings encrypted in transit and at rest. Every note is an editable draft until you review and sign it.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.