Pre Op Note Template and Drafting Guide

A comprehensive pre-op note must document the patient's current physiological state and surgical readiness. Key sections include a focused history of present illness, a review of comorbidities (such as hypertension or diabetes), current medications with specific hold instructions, and a clear statement of the patient's understanding of the procedure and risks. Documentation should explicitly state the NPO status and whether medical clearance from primary care or cardiology has been obtained and reviewed.

Using Aduvera to draft these notes eliminates the need to recall specific details from memory after the visit. The AI scribe captures the nuances of the pre-surgical conversation and organizes them into the required sections, allowing the clinician to focus on verifying the medical accuracy of the draft rather than formatting the text. This ensures that critical safety checkpoints are documented without the burden of manual transcription.