AI scribe and clinic software for general surgery clinics

The general surgery note, from history to listing

A surgical clinic note has a settled order. Presenting complaint and duration, relevant history such as previous abdominal surgery, anticoagulants, smoking and body mass index, the examination with side, site, size and whether a hernia reduces, the investigations, the diagnosis, the options and the decision. wai's clinic template holds that order for every surgeon in the practice, and the surgeon reads the same captured note as SOAP, problem-oriented, narrative or a bullet summary, whichever suits the day.

Guidelines decide what some of those lines must show. For suspected gallstone disease NICE recommends liver function tests and ultrasound, offers laparoscopic cholecystectomy to people with symptomatic gallbladder stones as a day case unless their circumstances make an inpatient stay necessary, and offers early surgery within 1 week of diagnosis for acute cholecystitis.³ A template that asks for the ultrasound date and finding, the liver function results and the planned setting keeps those facts in the note and in the letter.

Codes come from the note. wai suggests ICD-10 and SNOMED CT codes, each shown with the line of the consultation it rests on, for the surgeon to confirm. Typical general surgery diagnoses in the WHO edition of ICD-10, used in the UK and the Gulf, include K40.9 for a unilateral or unspecified inguinal hernia without obstruction or gangrene, K42.9 for an umbilical hernia without obstruction or gangrene, K80.2 for calculus of gallbladder without cholecystitis, K64.2 for third degree haemorrhoids and L05.9 for a pilonidal cyst without abscess. US practices code in ICD-10-CM, where the same inguinal hernia becomes K40.90 when it is not specified as recurrent. Procedure codes, OPCS-4 in the UK and CPT in the US, stay with the clinic's coder.

The letters a surgical clinic sends, and to whom

The first letter goes to the patient. The Academy of Medical Royal Colleges recommends that most outpatient letters are written directly to the patient with a copy to the GP, and that writing to patients should be the default for an AI scribe.⁴ wai drafts it that way, in plain words, with the diagnosis, the options, the decision and what happens next.

The same letter can carry the consent record. The Royal College of Surgeons of England asks surgeons to keep a written decision-making record of the key points of the consent discussion and the patient's decision, even when the patient decides against surgery, and says it could take the form of a letter to the patient and their GP or referring doctor.² 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.¹ The draft lists the alternatives, the risks the surgeon described and the patient's own questions in the words used. The signed consent form stays a separate document.

Other letters follow from the same consultation. A reply to the referring GP or physician answers the question that was asked. A referral onward, to a gastroenterologist or a radiologist, carries the questions for the specialist, as set out in the referral letter. A results letter explains the histology after an excision. After surgery, the review letter records the wound, the histology and the return to work advice, and a UK fit note goes out on the official form. Each one waits for the surgeon's signature and downloads as a PDF.

Consent 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.

In surgery the language of the consent conversation matters most. A patient who weighed the risks of a hernia repair in Arabic or Polish should be able to read them again in that language, so the patient summary can be translated beside the English letter, with crisis and emergency numbers kept exactly as written. The wound warning signs and the number to call read the same way. More is on the multilingual AI scribe page and in the guide to multilingual consultations.

Clinic software for general surgery clinics, from enquiry to discharge

Most surgical admin is about dates. Calls, email, web forms and WhatsApp messages land in one thread per patient, and wai drafts each reply in the clinic's voice for a person to approve before it is sent. Patients request new and follow-up appointments through booking links that read each surgeon's own calendar in Google, Outlook or Apple, a cancelled clinic slot is offered to the waitlist, and reminders go out before every visit.

Money and tests run from the same record. Deposits for a self-pay operation, invoices and payment links go through the clinic's own Stripe account, and insured patients get insurer invoices. In the UK, pre-operative bloods are ordered through TDL with results back to the record, each result reaches the patient with the surgeon's own comment and a plain explanation of each marker, and private prescriptions for post-operative pain relief are issued and signed through SignatureRx.

After clinic, the signed plan goes home in plain words, and the after-visit companion tracks each referral, prescription and follow-up until it is done, including the wound check and the histology review. Before every visit the surgeon sees a sourced brief of the patient, each fact traced to the letter, result or visit it came from. The theatre list itself stays with the hospital where the surgeon operates. The full set of admin flows is on the clinic management software page.

One hernia consultation, start to finish

Take a 52-year-old delivery driver with a right groin lump for six months that aches after lifting. He has had no abdominal surgery, takes no anticoagulants and stopped smoking four years ago. The surgeon examines him standing and lying, finds a reducible right inguinal hernia with a cough impulse, and talks through watchful waiting, a laparoscopic repair and an open mesh repair, with the risks she would want him to know, including chronic groin pain, recurrence, bleeding, infection and difficulty passing urine after surgery. He asks how soon he can drive his van and lift parcels again.

The draft is ready as he leaves. It holds the history, the examination with side and findings, the diagnosis with ICD-10 K40.9 suggested beside the line where the surgeon named it, the three options, the risks as she described them, his question about work, and his decision for a laparoscopic repair as a day case. The surgeon reads the side twice and corrects one line. The draft said he could drive after two weeks, where she had said he could drive once he could make an emergency stop without pain, usually around two weeks, so she restores her own wording. She confirms the code and signs.

The letter goes to him with a copy to his GP, written to him, with the consent discussion inside it. The front desk sends the deposit link through the clinic's Stripe account, offers a pre-assessment slot from the booking link, and the after-visit companion opens the follow-up for his wound check. His fit note waits until the operation date is set.

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.⁵ wai is built on that finding, so it takes on the letters, the replies, the booking and the follow-up as well as the note.

Surgery's own guidance asks for a record of the conversation as well as the signature. The Royal College of Surgeons of England expects a contemporaneous record of the key points of the consent discussion alongside the form,² and Montgomery made dialogue part of the duty to advise.¹ An ambient draft captures that dialogue in the words used, for the surgeon to check.

A draft stays a draft until the surgeon signs it. NHS England publishes guidance on the use of AI-enabled ambient scribing products in health and care settings,⁷ and wai holds every draft until the clinician signs it, and every reply until a person at the clinic sends it. Language matters too. In a systematic review of 33 studies, 76% found at least one outcome better when patient and physician shared a language other than English.⁶

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 surgeon and one clinic type, such as new hernia and gallbladder referrals. In the first week, build the letter template to the patient-first structure with fixed fields for side, site and investigation date, add the consent record fields, and run it for every new patient. Measure the time from the end of clinic to signed letters, and count corrections to side and to risks.

In the second week, add the listing details and the post-operative review template, and turn on booking links and deposit links at the front desk. Before go-live, record patient consent to ambient capture as set out in patient consent for AI scribes, and read the medico-legal guide with the surgeons. The anaesthetic side of the same patient is in the anaesthesia guide, other specialties are on the specialties page, and plans are on the pricing page.

Frequently asked questions