AI Medical Scribe for
Pre-anesthesia assessments, consent discussions, and PACU handoffs all generate charting that competes with your next case. Medical Scribe captures the conversation and drafts the note while you stay heads-up with the patient.
A real example of the documentation Medical Scribe generates for nurse anesthetists — ready before your patient leaves the room.
58F scheduled for laparoscopic cholecystectomy. Prior uneventful general anesthesia for cesarean section; denies PONV or family history of anesthetic complications. Anxious about awareness under anesthesia — reassurance provided. NPO since midnight confirmed.
ASA II — well-controlled hypertension and type 2 diabetes. No predictors of difficult airway. Cleared to proceed with general anesthesia.
PACU handoff to include airway grade, intraoperative fluids, and analgesia administered. Post-op visit to reassess pain control, PONV, and any airway complaints.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
From pre-op bay to induction can be minutes. Assessments stack up across a full OR schedule and get written from memory after the last case of the day.
Mallampati class, ASA status, NPO confirmation, anticoagulants held or not — these details decide anesthetic plans and get scrutinized if anything goes wrong. Thin notes are exposure.
Pre-anesthesia evaluation, consent discussion, post-op follow-up — one patient can mean three separate documents before you're done with the case.
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.
A CRNA’s documentation follows the patient through the whole perioperative arc. Record the pre-anesthesia interview as you conduct it — history, airway exam spoken aloud, NPO confirmation, consent discussion — and Medical Scribe drafts the note before the patient rolls back. Post-op follow-ups and PACU handoffs work the same way, in person or by telehealth.
The generated note follows the built-in Nurse Anaesthetist’s note template: Patient Information, Subjective, Objective, Assessment, Plan, Interventions, Evaluation, and Plan for Continuing Care. Verbalized findings — Mallampati class, held medications, lab review — are structured into the right sections, alongside the anesthetic plan and PONV prophylaxis you discussed with the patient.
Anesthesia carries some of the highest documentation stakes in the hospital. When a case is reviewed, what matters is what was assessed and disclosed before induction. Medical Scribe records only what was actually said and observed — so your pre-anesthesia note reflects the real encounter, not an end-of-day reconstruction, and you sign every word of it.
Yes. The built-in Nurse Anaesthetist's note template structures the encounter from Subjective and Objective through Assessment, Plan, Interventions, Evaluation, and Plan for Continuing Care — so airway exam, ASA class, and NPO status each land where reviewers expect them.
Yes. Medical Scribe runs on iOS, Android, Web, Apple Watch, and Mac, and records in-person conversations at the bedside as well as telehealth pre-op calls. You can dictate a PACU handoff summary the moment you give report.
No. The note contains only what was said or observed during the encounter — it never invents a Mallampati class, lab value, or consent discussion. You review and sign before anything enters the chart.
Medical Scribe is HIPAA compliant with encryption in transit and at rest. Notes are editable drafts until you approve them, and SOAP, DAP, and custom formats are supported if your group charts differently.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.