In the field of general surgery, precise and comprehensive clinical documentation is crucial for delivering high-quality patient care. A well-structured surgical review note not only facilitates effective communication among healthcare providers but also ensures accurate medical records. Here, we will guide you through the process of creating and formatting a surgical review note using a detailed template, followed by an example to illustrate each section. We will also explore how AI medical scribes, like Notis AI Medical Scribe, can streamline and enhance the documentation process for general surgeons.

Step-by-Step Guide to Writing Surgical Review Documentation

Patient Information

Begin your surgical review note with the patient's basic details. Include the patient's name, age, gender, and medical record number. For example:

Patient Information:

• John Doe

• 45

• Male

• 123456

Presenting Complaint

Outline the main issue that brought the patient to seek medical attention. This section should be concise yet descriptive. Example:

Presenting Complaint: Abdominal pain and bloating for the past two weeks.

History of Presenting Complaint

Detail the chronological development of the patient’s symptoms. Include onset, duration, character, and any associated symptoms. Example:

History of Presenting Complaint: The patient reports a gradual onset of abdominal pain, which has been persistent and worsening over the last two weeks. The pain is described as a dull ache, primarily in the lower abdomen, and is associated with bloating and occasional nausea.

Past Medical History

Document any previous medical conditions or surgeries. Example:

Past Medical History: Appendectomy in 2010, hypertension.

Medications

List the medications the patient is currently taking, including dosages. Example:

Medications: Lisinopril 10 mg daily, multivitamin.

Allergies

Include known allergies and reactions. Example:

Allergies: Penicillin (rash).

Family History

Note any relevant family medical history that might aid in diagnosis or treatment. Example:

Family History: Father had colon cancer at age 60.

Social History

Provide information on lifestyle factors that may impact health. Example:

Social History: Works as an accountant, non-smoker, drinks alcohol socially, no recreational drug use.

Review of Systems

Conduct a systematic inquiry of symptoms related to various body systems. Example:

Review of Systems: Positive for abdominal discomfort and bloating. Negative for fever, weight loss, or changes in bowel habits.

Physical Examination

Describe the significant findings from the physical examination. Example:

Physical Examination: Vital signs: BP 130/85, HR 78, Temp 98.6°F. General appearance: alert and oriented. Abdominal examination: mild tenderness in the lower quadrants, no rebound tenderness, normal bowel sounds.

Investigations

List the investigations ordered or conducted to support diagnosis. Example:

Investigations: Ordered abdominal ultrasound and complete blood count.

Impression

Summarize the preliminary diagnosis or clinical impression based on the information gathered. Example:

Impression: Possible diverticulitis or other gastrointestinal pathology.

Plan

Outline the management plan, including treatment and follow-up. Example:

Plan: Start on a clear liquid diet, prescribe antibiotics (Ciprofloxacin and Metronidazole), and schedule a follow-up in one week. Educate the patient on signs of complications and when to seek immediate care.

Enhancing Surgical Documentation with Notis AI Medical Scribe

Documenting surgical reviews can be time-consuming and labor-intensive, yet it is an essential component of patient care. This is where AI medical scribes, like Notis AI Medical Scribe, come into play, particularly for general surgeons.

Automating Documentation

Notis significantly reduces the time spent on patient documentation by transforming verbal consultations into structured SOAP notes. This automation allows general surgeons to focus more on patient care rather than administrative tasks.

Improving Efficiency and Accuracy

With its high accuracy in transcribing medical notes, Notis ensures that clinical documentation is precise and comprehensive. This leads to better patient charting and reduces errors associated with manual documentation.

Seamless Integration

Operating through a familiar platform like WhatsApp, Notis eliminates the need for additional software, simplifying the workflow for general surgeons. This ease of use and integration enhances the documentation process, making it more efficient.

In summary, mastering surgical review documentation is vital for effective patient care in general surgery. With the advent of AI medical scribes like Notis, the process becomes not only more efficient but also more accurate, allowing surgeons to dedicate more time to their patients.