AI Medical Scribe for
Clinic sits between OR days, and every consult, pre-op, and post-op check adds to the note pile. Medical Scribe drafts each visit's note from the conversation — operative indication, consent discussion, and follow-up plan included — whatever you operate on.
A real example of the documentation Medical Scribe generates for surgeons — ready before your patient leaves the room.
44F referred with recurrent right upper quadrant pain, 4 episodes over 6 months, each 2-4 hours after fatty meals, the latest requiring an ED visit. No fever or jaundice. Past history: two cesarean sections; hypertension on amlodipine 5mg daily. Non-smoker, occasional alcohol. NKDA. Works as a school administrator.
Discussed risks including bile duct injury, bleeding, infection, and retained stones; expectant management offered as alternative with recurrence risk explained. Patient elects surgery; written consent obtained. Advised to present to ED if fever, jaundice, or persistent pain before the operative date.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
A full consult list gets squeezed into the days you're not operating. Each new patient needs a complete workup note, each post-op a wound and recovery check — and dictation backlog follows you home.
When an outcome is disputed, the clinic note is exhibit A: was the indication sound, were alternatives offered, was consent informed? A two-line note can't answer any of that.
Anticoagulation holds, anesthesia clearance, fasting instructions, follow-up intervals — surgical plans are logistics-dense, and a missed detail in the note becomes a cancelled case or a phone call from pre-admission.
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 surgical practice, whatever the organ system, cycles through the same three encounters: the new referral where the operative decision is made, the pre-op confirmation, and the post-op review. Medical Scribe records each and drafts the note in the visit’s own structure, so OR days stop ending with a dictation queue.
Generated notes follow the Surgeon’s note template: Subjective covering the presenting complaint, surgical history, medications including anticoagulants, and social risk factors; Objective with exam and investigations; and a per-issue Assessment & Plan spanning differential, planned procedure, pre-operative preparation, and post-operative care — with consent and patient concerns in Additional Notes.
Surgery is the specialty where notes end up in front of lawyers. Medical Scribe documents only what was said and observed in the encounter — the indication you articulated, the risks you actually listed — and never invents findings. Every note is yours to edit and sign before it enters the chart.
Yes — that breadth is the design. The Surgeon's note is a consult format built around operative decision-making, and the 280+ built-in templates include dedicated notes for vascular, colorectal, trauma, breast, hand, hepatobiliary, transplant, pediatric, and plastic and reconstructive surgeons, among many others. Custom templates take minutes if your practice charts differently.
The consent discussion is drafted from what was actually said: the specific risks you named, the alternatives you offered, the patient's decision. It's captured under Additional Notes in the Surgeon's note, and it never includes a risk or alternative that wasn't actually discussed.
The Assessment & Plan section includes pre-operative preparation as stated in the visit: medication holds, fasting instructions, required clearances, and referrals. If you said it, it's in the plan; you verify everything at review before signing.
Yes. A five-minute wound check — in clinic or over video — produces a short, structured follow-up note. Medical Scribe works on iOS, Android, Web, Apple Watch, and Mac, and is HIPAA compliant with encryption in transit and at rest.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.