AI scribe and clinic software for anaesthesia and pre-operative assessment

The pre-operative assessment note, system by system

A pre-assessment note has a fixed shape. The planned procedure and its surgical grade, cardiovascular and respiratory history, functional capacity such as stairs climbed without stopping, sleep apnoea screening, previous anaesthetics and any problems, family history of anaesthetic complications, medicines including anticoagulants, allergies, the examination, the airway assessment, the tests, the provisional ASA grade and the plan. wai's template holds that order for every anaesthetist in the clinic, and the anaesthetist reads the same captured note as SOAP, problem-oriented, narrative or a bullet summary.

The airway and the ASA grade are said aloud and checked. Mouth opening, Mallampati class, thyromental distance, neck movement, dentition and beard go into fixed fields as the anaesthetist examines. The ASA statement describes the classification as a way to assess and communicate a patient's pre-anaesthesia comorbidities, and says the final grade is assigned by the anaesthesiologist on the day of anaesthesia care after evaluating the patient.¹ NICE notes that UK anaesthetists often read the grades in terms of functional capacity, comorbidity that does not limit activity at ASA 2 and comorbidity that does at ASA 3.² The template therefore marks the clinic grade as provisional.

Tests follow the grade of surgery and the patient. NICE NG45 advises against routine chest X-rays, routine urine dipsticks and routine HbA1c in people without diabetes before surgery, offers HbA1c to people with diabetes who have not been tested in the last 3 months, and considers resting echocardiography only for a heart murmur with cardiac symptoms or signs of heart failure, after an ECG has been discussed with an anaesthetist.² It also asks that every discussion with women about whether to carry out a pregnancy test is documented.² The draft records each test with its reason, so an unnecessary one stands out.

wai suggests ICD-10 and SNOMED CT codes from the note, each shown with the line it rests on, for the anaesthetist to confirm. In the WHO edition of ICD-10 used in the UK and the Gulf, typical codes are Z01.8 for other specified special examinations, G47.3 for sleep apnoea, E66.9 for obesity, unspecified, I10 for essential hypertension, Z88.4 for personal history of allergy to anaesthetic agent and T88.3 for malignant hyperthermia due to anaesthesia. US practices code in ICD-10-CM, where the pre-assessment visit itself is Z01.818, encounter for other preprocedural examination. Procedure and anaesthesia billing codes, OPCS-4 in the UK and CPT in the US, stay with the clinic's coder.

wai is not in theatre. It does not record the intraoperative anaesthetic chart, the drugs and doses given, the times or the monitoring, all of which stay on the anaesthetic record. Where it helps on the day of surgery is the conversation before it, which it can capture as it would any consultation, and the follow-up visit after.

Letters after pre-assessment, and the consent record

The Academy of Medical Royal Colleges recommends that most outpatient letters are written to the patient with a copy to the GP, and that this should be the default for an AI scribe.⁵ After pre-assessment the letter goes to the patient, copied to the GP and the surgeon, and states what was agreed, the medicine instructions the anaesthetist set and what happens next. Medication change letters set out each medicine to stop or adjust, from when and when to restart.

The risk discussion is part of the record. Under Montgomery a risk is material if a reasonable person in the patient's position would be likely to attach significance to it, or if the doctor should reasonably be aware that this patient would, and advising requires dialogue.⁴ The Association of Anaesthetists published new consent guidelines in 2026, with a section on peri-operative medicine and updated advice on the timing, mode, conduct and content of consent discussions.³ The draft records the options discussed, the risks described and the patient's questions in the words used.

Some letters ask colleagues for help. An optimisation letter to the GP asks for a specific change, such as blood pressure control or an HbA1c, with the readings behind it. A referral letter to a sleep service or a cardiologist carries the questions for the specialist, as set out in the referral letter. Patients on long-term opioids can be referred to the pain team the same way, and the pain management guide covers that clinic. Every letter waits for the anaesthetist's signature and downloads as a PDF.

Pre-operative instructions in the patient's own language

wai works in 60 languages, among them English, Arabic, Spanish, French, Portuguese, Italian, Russian, Polish, Turkish, Urdu and Mandarin. English can be mixed in one consultation with Spanish, French, Portuguese, Russian, Italian, Dutch, German, Hindi or Japanese, and the other languages are captured in that language. The signed note is written in English for the record, or in another language the clinic chooses.

The lines that matter most on the morning of surgery are which tablets to take, which to stop and when to stop eating and drinking. The patient summary can be translated into the patient's language beside the English letter, with crisis and emergency numbers kept exactly as written, so a patient who discussed the anaesthetic in Turkish or Mandarin reads the instructions the anaesthetist signed in that language. More is on the multilingual AI scribe page.

Clinic software for pre-operative assessment clinics

Pre-assessment is a scheduling problem as much as a clinical one. Patients request a slot through booking links that read each anaesthetist's calendar in Google, Outlook or Apple, a video pre-assessment works the same way because the scribe joins Google Meet, Zoom and Microsoft Teams calls, cancellations are offered to the waitlist, and reminders go out before the visit and before the operation date.

Tests run from the same record. In the UK, pre-operative bloods are ordered through TDL with results back to the record, and each result reaches the patient with the anaesthetist's own comment and a plain explanation of each marker. The after-visit companion tracks each referral, optimisation request and follow-up until it is done, so the operation date does not arrive with an open question.

Patients ask about medicines before surgery, and calls, email, web forms and WhatsApp messages land in one thread per patient, with replies drafted in the clinic's voice for a person to approve. Before each visit the anaesthetist sees a sourced brief of the patient, so a previous difficult intubation or an allergy appears with the letter or result it came from. Family and carer access is available with the patient's consent, and invoices and insurer invoices go through the clinic's own Stripe account. The full set is on the clinic management software page.

One pre-operative assessment, start to finish

Take a 63-year-old man listed for a laparoscopic cholecystectomy, seen on video two weeks before surgery. His body mass index is 36, his blood pressure is well controlled on two medicines, and his wife has told him he stops breathing when he snores. He climbs two flights of stairs without stopping. He had a general anaesthetic in 2015 and was very sick afterwards, and there is no family history of anaesthetic problems. The anaesthetist asks him to open his mouth and move his neck on camera, talks through a general anaesthetic, the plan to reduce sickness this time, and the risks she would want him to know, and he asks whether his snoring could cause a problem.

The draft is ready when the call ends. It holds the history by system, the sleep apnoea concern, the functional capacity, the airway findings as she described them, his previous sickness, the medicines and the provisional grade she stated, ASA 2, with the reason. She moves one item. The draft had recorded his sickness after the 2015 anaesthetic in the history, and she adds it to the plan as well, with the prevention she had discussed. ICD-10 Z01.8 is suggested for the visit and E66.9 beside the line on his weight, and she confirms both and signs.

The letter goes to him, copied to his GP and the surgeon, with the medicine instructions she set. A referral letter to a sleep service carries her question about suspected sleep apnoea before surgery. The front desk orders the bloods she chose through TDL, the after-visit companion tracks the sleep referral, and the reminder before his operation date carries the instructions she signed, approved by a person before it goes. The surgical side of the same patient is in the general surgery guide.

The evidence behind wai's method

The note is one part of the day the evidence measures. In a randomised trial of 238 outpatient physicians across 14 specialties at UCLA Health, the ambient scribe with a significant effect cut the time spent writing each note by about 41 seconds, against 18 seconds in usual care.⁶ wai is built on that finding, so it takes on the letters, the tests, the booking and the follow-up as well as the note.

Anaesthesia's own standards depend on the record. The ASA leaves the final grade to the anaesthesiologist on the day,¹ and NICE asks for documented discussions and tests chosen for a reason.² A template that marks the clinic grade as provisional and records each test with its reason keeps the note honest for whoever anaesthetises the patient.

A draft stays a draft until the anaesthetist signs it. wai holds every draft until the clinician signs it, and every reply until a person at the clinic sends it. In a systematic review of 33 studies, 76% found at least one outcome better when patient and physician shared a language other than English.⁷

Measured in a working clinic. At The Wellness in London, which runs on wai every day, every clinician has 15 hours a week back, as published in the customer story.⁸

Where to start

Start with one anaesthetist's pre-assessment clinic, in person or on video. In the first week, build the template with fields for surgical grade, airway, provisional ASA grade, tests with reasons and the medicine plan, and run it for every patient. Measure the time from the end of clinic to signed letters, and count corrections to medicine instructions and allergies.

In the second week, add the medication change letter and the optimisation letter, and turn on booking links and pre-operative bloods at the front desk. Record patient consent to ambient capture as described in patient consent for AI scribes. The scribe is described on the wai Clinicians page, other specialties are on the specialties page, and plans are on the pricing page.

Frequently asked questions