Does it record the consent discussion?

Yes, when it happens: the procedure and the risks, benefits and alternatives you explained. It never states that consent was obtained unless you said so.

Does it work for post-operative clinics?

Yes. Wound, drain and suture findings have their own section.

Can I use the General Surgery template for ward notes?

Yes. Specialty templates work for outpatient clinic notes and inpatient ward notes.

What if I also have my own template?

Both are used together: your own sections first, then the specialty sections.

General Surgery template

General Surgery notes, written while you talk

Surgical clinic notes need previous operations, the local examination and the consent discussion in one place. The General Surgery template covers pre-operative and post-operative visits alike.

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Built for a General Surgery clinic

The consultations this template is laid out for, among others:

Inguinal and umbilical hernia
Gallstones
Lumps and cysts
Haemorrhoids
Post-operative review
Wound care

See a General Surgery note

A short consultation in Urdu, and the note Hikayat Scribe writes from it.

The consultation (Urdu)

Patient: Daayein taraf naaf ke neeche soojan hai. Khansne pe bahar aati hai. Chhe mahine se.

Doctor: Dard?

Patient: Halka sa.

Doctor: Right inguinal region mein reducible swelling, cough impulse positive. Operation ki zaroorat hogi, list pe daal dete hain.

The note

Presenting complaint: Right groin swelling x6/12, mild pain.
Local examination: Right inguinal region: reducible swelling, cough impulse positive.
Pain assessment: Mild pain, right groin.
Plan: Listed for surgery.

Fictional patient. Sections that were not discussed are left off.

What the General Surgery template records

Alongside the usual history and examination, every General Surgery note has these sections:

Previous operations and anaesthesiaLocal examinationPre-operative considerationsProcedure and consent discussionPost-operative reviewPain assessmentPatient education

Only what was discussed

The scribe never states that consent was obtained unless it was said in the consultation. Any section that was not covered is simply left off the note, so it never fills up with "not discussed".

Set it once

Choose General Surgery when you start a clinic or ward note, or tick "Always start my notes with this specialty" and it stays selected until you change it. Specialty templates are part of Pro and Enterprise, and included in the 7-day free trial.

The rest of the note

Ranked differentials with the reasoning shown, for you to choose from
Investigations and medicines you tick yourself; nothing is prescribed until you do
ICD-10 and SNOMED codes for your review
Your name, qualifications, registration number and the date and time on the printed note

How it works

Record. Press the button and talk with your patient in any of nine languages, or dictate on your own.
Review. The note is ready in seconds. Tick the diagnosis, investigations and medicines you are keeping, and edit anything.
Use it. Copy, print or email the note, with your name, qualifications and registration number on it.

Common questions

Does it record the consent discussion?: Yes, when it happens: the procedure and the risks, benefits and alternatives you explained. It never states that consent was obtained unless you said so.
Does it work for post-operative clinics?: Yes. Wound, drain and suture findings have their own section.
Can I use the General Surgery template for ward notes?: Yes. Specialty templates work for outpatient clinic notes and inpatient ward notes.
What if I also have my own template?: Both are used together: your own sections first, then the specialty sections.

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