Preoperative Note Sample and Drafting Guide

A strong preoperative note must clearly document the patient's fitness for surgery. Essential sections include the surgical indication, a focused review of systems, current medications, known allergies, and a detailed physical exam focusing on the airway and cardiovascular stability. It should explicitly state the planned procedure, the informed consent process, and the anesthesia risk classification to ensure all members of the surgical team are aligned before the patient enters the OR.

Rather than manually typing these sections or relying on a static sample, clinicians can use Aduvera to capture these details during the actual pre-op encounter. The AI medical scribe identifies the key clinical data points from the recording and maps them into a structured draft. This eliminates the need to recall specific patient details from memory, providing a transcript-backed first pass that the clinician can review and refine before finalizing the note.