Anesthesiology

Ambient documentation for pre-op and pain clinics

Pre-anesthesia assessments and chronic pain visits produce dense notes. ScribeMDPro drafts them from the conversation.

Where anesthesiology intersects with documentation-heavy outpatient work is in the pre-anesthesia assessment clinic and in interventional pain practices. Pre-op assessments require structured capture of airway, cardiac risk, medication history and anesthesia plan. Chronic pain visits are among the most documentation-heavy in medicine, spanning symptom review, opioid stewardship, procedural history and controlled substance monitoring. ScribeMDPro was configured for both — the pre-op template captures airway, cardiac risk stratification (RCRI, METS) and anesthesia plan discussion, and the pain clinic template supports opioid risk assessment and controlled substance documentation.

Documentation challenges we solve

  • Pre-op assessment requires structured airway, cardiac and medication capture
  • Chronic pain visits carry significant regulatory documentation requirements
  • Interventional procedure documentation (epidural, facet, RF ablation) needs precise site and technique detail
  • Controlled substance prescribing decisions must be defensible in the note

What clinicians gain

  • Pre-op template with airway, cardiac risk (RCRI/METS) and anesthesia plan discussion
  • Chronic pain visit template with opioid risk assessment fields
  • Interventional procedure notes with site, technique, contrast, medications
  • Controlled substance rationale documented explicitly

How it works

  1. Step 1
    Start ambient capture

    Open ScribeMDPro before the anesthesiology / pain encounter and start recording — the patient never has to talk to a device.

  2. Step 2
    Focus on the patient

    Conduct your normal history and exam. Perform pre-op assessment or pain visit as usual — the note is drafted from the conversation and any procedural details.

  3. Step 3
    Auto-drafted note

    A structured SOAP note appears seconds after the visit ends, formatted for your specialty.

  4. Step 4
    Review, sign, export

    Edit inline, copy to your EMR, download as PDF, or push through supported integrations.

Example SOAP output

Pre-op: 62yo F for elective total knee arthroplasty. PMH: HTN, T2DM, mild OSA (CPAP-tolerant). METS >4. Airway: MP II, TMD >6cm, full neck ROM. No prior anesthesia complications.
A: ASA III, low-intermediate cardiac risk. OSA-optimized.
P: Neuraxial anesthesia with adductor canal block; general anesthesia backup. Continue anti-hypertensives on morning of surgery, hold SGLT2i 3 days pre-op. CPAP available in PACU.

Illustrative only. Clinicians retain final responsibility for the record.

Frequently asked questions

Does it work in pre-anesthesia assessment clinics?

Yes — the pre-op template covers airway, cardiac risk stratification, medication reconciliation and anesthesia plan.

Is it suitable for chronic pain practices?

Yes. Chronic pain templates include opioid risk assessment fields and controlled substance documentation.

Can it document interventional procedures?

Epidurals, facet injections, RF ablations and other pain procedures have templates with site, technique and medications.

What about intra-op documentation?

Intra-op record capture is not a primary use case; ScribeMDPro focuses on the conversational documentation surrounding anesthesia and pain care.

Related pages

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