An AI medical scribe for general surgery

Surgical clinics move fast: new referrals for hernias and gallstones, consent conversations, wound checks and histology results, often with a list to get to afterwards. ClearPass transcribes the clinic conversation and drafts the note, and lets you dictate an operation note in a structure that suits it.

What surgical notes need to show

A surgical clinic note is read by the anaesthetist, the ward team and sometimes a reviewer months later. It has to show why you decided to operate or not, and that the patient understood the choice.

• Symptoms with their pattern: pain site and triggers, episodes of biliary colic, hernia discomfort on lifting, obstructive features, weight loss.
• Previous abdominal operations, anticoagulants and antiplatelets, diabetes, smoking, BMI, and anything that changes the anaesthetic risk.
• Examination with side and size: reducible or not, cough impulse, tenderness, scars, and a clear statement of laterality.
• Investigations: ultrasound findings, liver tests, CT, endoscopy, with dates.
• The options discussed, including watchful waiting, and the specific risks you explained, since a consent discussion is only as good as its documentation.
• Post-operative review: wound, drain output, pain, eating, bowels, mobility, and the histology result with what it means for follow-up.

Example: new referral with gallstones

History: Man in his fifties with three episodes of right upper quadrant pain after fatty meals over four months, each lasting 2 to 3 hours, one attendance for analgesia. No jaundice, no fever, no pale stools. Previous open appendicectomy. Takes amlodipine. Non-smoker. BMI 31.
Examination: Mild tenderness right upper quadrant, Murphy sign negative today. Right iliac fossa scar well healed. No hernia.
Investigations: Ultrasound shows multiple gallstones, gallbladder wall 3 mm, common bile duct 5 mm. Liver tests normal.
Impression: Symptomatic gallstones, uncomplicated.
Plan: Discussed laparoscopic cholecystectomy versus conservative management with dietary change. Risks explained: bleeding, infection, bile leak, bile duct injury, conversion to open, retained stones. Patient wishes to proceed. Added to the list for day-case surgery. Pre-assessment booked.

Operation notes and procedure notes

Transcribe is built for the conversation with the patient. For the operation note, use the Procedure structure and dictate or type it after the case: indication, procedure performed, anaesthetic, findings, steps, closure, estimated blood loss, specimens sent, and post-operative instructions. The draft comes back in order, ready to check and paste into your system. See the procedure note template for the layout.

There is no general surgery group among the guided templates. The General group's Procedure request case and the Emergency / Critical Care group's Acute abdomen case are the nearest; otherwise use free text with New patient, Follow-up or Procedure, or build your own headings once with My own structure.

Letters and codes surgeons need

• Referral letter back to the family doctor after the clinic, with the decision and what happens next.
• Patient instructions: wound care, when to shower, driving and lifting, warning signs after discharge. See the patient instructions template.
• Sick note covering the recovery period.
• Prior authorization for a planned operation; for weight-loss surgery see prior authorization for bariatric surgery.
• ICD-10 and procedure (CPT) codes from the same visit where your country uses them. Check every code before it goes on a claim.

Reviewing a surgical draft

1. Check laterality everywhere it appears. Left and right in the history, the examination and the plan must agree.
2. Check the consent paragraph. The risks listed should be the ones you actually discussed. Add any you mentioned that the draft missed, and remove any it added.
3. Check anticoagulant instructions. When to stop and restart is safety-critical. The Numbers check marks any day count or dose that was never said.
4. Check sizes and measurements. Hernia defect size, duct diameter and wall thickness are easy to mishear.

What ClearPass does not do

• It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
• It is not a medical device and does not make clinical decisions. It is a documentation aid.
• It does not connect to your EMR. The note is copy-ready text that pastes into any system.

Privacy

Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.

Questions

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