AI scribe and clinic software for plastic and cosmetic surgery

The plastic surgery record, reconstructive and cosmetic

A reconstructive note follows the defect. Referral reason, the lesion or scar with site, side and size, the histology if it is known, the patient's smoking status and anticoagulants, the examination, the reconstruction options from direct closure to graft or flap, the decision and the plan for histology review. wai's template holds that order, and the surgeon reads the same captured note as SOAP, problem-oriented, narrative or a bullet summary.

A cosmetic note carries more, because the GMC asks for more. Doctors must ask why the patient wants the intervention and the outcome they hope for before assessing whether it is appropriate, consider the patient's vulnerabilities and psychological needs, tell the patient about alternatives that could meet their needs with less risk, discuss the physical and psychological impact if the result fails to meet expectations, and say whether implanted devices may need to be removed or replaced and after how long.¹ Charges must be explained clearly, including what a quoted price covers.¹ The Royal College of Surgeons of England adds the patient's previous cosmetic procedures, the quality of evidence for the procedure, the likely effect on day-to-day life and fees for managing complications.² wai's cosmetic template has a field for each, so a missing item shows before signing.

Consent has its own rules in the UK. The GMC says the doctor who will carry out the intervention must seek consent and must not delegate it, and that the time a patient needs to reflect depends on how invasive, complex, permanent and risky the procedure is.¹ The Royal College of Surgeons of England asks for consent in two stages with a cooling-off period of at least two weeks between them, with good reasons recorded if that is not possible, and for written agreement before photographs are used for anything beyond the patient's record, such as marketing.² These are UK standards. Clinics in the US, the Gulf or Europe set the interval by their own regulator, and the template field holds whichever applies. wai does not take or store clinical photographs. The note records what the patient agreed to and what they declined.

wai suggests ICD-10 and SNOMED CT codes from the note, each shown with the line it rests on, for the surgeon to confirm. In the WHO edition of ICD-10 used in the UK and the Gulf, typical codes are Z41.1 for other plastic surgery for unacceptable cosmetic appearance, N62 for hypertrophy of breast, L90.5 for scar conditions and fibrosis of skin, L91.0 for hypertrophic scar, C44.3 for a malignant neoplasm of skin of other and unspecified parts of face and Z42.1 for follow-up care involving plastic surgery of breast. In US ICD-10-CM, Z41.1 reads encounter for cosmetic surgery and a basal cell carcinoma of the skin of the nose is C44.311. Procedure codes, OPCS-4 in the UK and CPT in the US, stay with the clinic's coder.

Letters for reconstructive and cosmetic patients

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.⁴ Cosmetic work adds a condition. The GMC asks doctors to consider whether the GP should be consulted, to seek the patient's permission, and to record it if the patient refuses.¹ wai drafts the letter to the patient and records the GP permission in the note, and the surgeon checks it before a copy goes to the GP.

The letter after a first cosmetic consultation does real work. The Royal College of Surgeons of England asks that information about the procedure reaches the patient at a different time from the signing of the consent form.² The draft gives a plain account of the options, the risks the surgeon described and what the fee includes, so the patient has it in writing during the cooling-off period. 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.³

After the operation the GMC asks for written information detailed enough for another professional to take over care, including the medicines or devices used, sent to the GP with the patient's consent.¹ Reconstructive work brings its own letters, replies to referring dermatologists and GPs, results letters for histology, and referral letters that carry the questions for the specialist, as described in the referral letter. Medico-legal and expert reports on scarring after injury are drafted from the consultation for the surgeon to sign. Every document downloads as a PDF once signed.

Consultations 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.

Cosmetic consent rests on the patient understanding risks and expectations, so the language of the conversation counts. A patient who travels to a London clinic and discusses a procedure in Arabic or Russian can read the patient summary in that language beside the English letter, with crisis and emergency numbers kept exactly as written. Aftercare instructions and the out-of-hours number read the same way. More is on the multilingual AI scribe page.

Clinic software for plastic surgery clinics, built for two-stage consent

Cosmetic practice starts with enquiries. 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. That approval step matters, because the GMC asks doctors to market their services responsibly.¹

The second consultation is the admin that two-stage consent creates. Patients request it through booking links that read the surgeon's calendar in Google, Outlook or Apple, and the person approving the message checks the date against the interval recorded in the note. Reminders go out before each visit, and cancelled slots are offered to the waitlist. Consultation invoices, deposits and payment links run through the clinic's own Stripe account, and reconstructive patients with cover get insurer invoices.

After surgery, the signed plan goes home in plain words, and the after-visit companion tracks each follow-up, wound check and histology result until it is done. Proactive care sends the recall for the scar review or the implant check the surgeon set, each message approved by a person. Before every visit the surgeon sees a sourced brief of the patient, including earlier procedures, each fact traced to the letter or visit it came from. The full set is on the clinic management software page.

One first cosmetic consultation, start to finish

Take a 34-year-old woman asking about breast augmentation after two children. The surgeon asks why she wants it and what she hopes for, and she says her clothes no longer fit the way they did and she wants to feel like herself. She has had no previous cosmetic procedures. The surgeon asks about her mood and wellbeing, examines and measures her, and talks through implant options, the alternative of no surgery, the risks including capsular contracture, rupture and the likelihood of further surgery, the expected recovery, and that implants may need replacing in the future. She agrees to photographs for her clinical record and declines any other use. She is happy for her GP to be told.

The draft is ready as she leaves. It holds her reasons and hopes in her own words, the history, the measurements, the options, the risks as the surgeon described them, the fees and what they include, the photo consent and the GP permission, and it records that consent will be taken at a second consultation at least two weeks later. The surgeon corrects one line. The draft had recorded agreement to photographs for marketing, from a question she had asked about the clinic's website, and the surgeon changes it to clinical record only, as she had said. ICD-10 Z41.1 is suggested beside the line naming the request, and the surgeon confirms it and signs.

The letter goes to her with a copy to her GP, setting out what was discussed while she decides. The front desk sends a booking link for the second consultation, checks the date she chooses against the interval in the note, and sends the reminder. The consultation invoice goes through the clinic's Stripe account. No deposit for surgery is taken until she has decided.

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.

Cosmetic guidance is specific about what the record shows. The GMC lists what the doctor must ask, explain and record,¹ and the Royal College of Surgeons of England sets the two stages, the cooling-off period and the photo consent.² An ambient draft captures the conversation in the words used, and a template field for each item makes a gap visible before the surgeon signs.

A draft stays a draft until the surgeon 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.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.⁷

Where to start

Start with one surgeon's first cosmetic consultations. In the first week, build the template with fields for motive and expectations, psychological history, alternatives, risks, fees, photo consent, GP permission and the second-consultation date, and run it for every new cosmetic patient. Measure the time from the end of clinic to signed letters, and count corrections to photo consent and to risks.

In the second week, add the reconstructive letter and the post-operative information template, and turn on second-consultation booking links at the front desk. Read the medico-legal guide with the surgeons, and see the dermatology guide for the skin cancer referrals that arrive in plastics clinic. The scribe itself is described on the wai Clinicians page, and other specialties are on the specialties page.

Frequently asked questions