AI Scribe for Neurosurgeons
Document spine surgery, cranial procedures, and neurological exams in seconds. PatientNotes captures instrumentation details, neuromonitoring findings, and precise anatomical documentation.
Documentation for Every Neurosurgical Encounter
From spine surgery to cranial procedures, PatientNotes handles all neurosurgical documentation needs
Spine Surgery
Discectomy, laminectomy, fusion procedures with instrumentation details and neuromonitoring.
Cranial Procedures
Craniotomy, tumor resection, aneurysm clipping with microsurgical technique documentation.
Post-Operative Management
Neurological checks, wound assessment, drain management, and complication monitoring.
Radiculopathy Consultations
Nerve root compression, imaging correlation, electrodiagnostic findings, and treatment planning.
Trauma Evaluations
Spinal cord injury, traumatic brain injury, skull fractures, and emergent surgical planning.
Pre-Operative Planning
Surgical indication, risk assessment, imaging review, neuromonitoring planning, and consent.
Neurosurgery-Specific Features
Built for the unique documentation needs of neurosurgical practice
Spinal Level Documentation
Precise documentation of spinal levels operated including verification methods, decompression extent, and instrumentation placement at each level.
Neurological Exam Templates
Structured documentation of cranial nerves, motor/sensory exams, reflexes, and gait with standardized grading and dermatomal mapping.
Instrumentation Tracking
Document screw trajectories, sizes, rod diameter, interbody cages, bone graft material with lot numbers for complete hardware documentation.
Neuromonitoring Integration
Capture SSEP, MEP, and EMG findings during surgery with alerts and changes documented in operative timeline.
Imaging Correlation
Integrate MRI and CT findings with clinical presentation. Document pathology location relative to anatomic landmarks and critical structures.
Complication Documentation
Structured templates for CSF leak, dural tear, nerve injury, and other neurosurgical complications with severity grading.
Sample AI-Generated Operative Report
See how PatientNotes documents a lumbar fusion procedure
OPERATIVE REPORT PATIENT: 58-year-old male DATE OF SURGERY: [Date] SURGEON: [Surgeon Name], MD ASSISTANT: [Assistant Name], MD ANESTHESIA: General endotracheal anesthesia with neuromonitoring PRE-OPERATIVE DIAGNOSIS: L4-L5 degenerative spondylolisthesis with spinal stenosis and bilateral radiculopathy POST-OPERATIVE DIAGNOSIS: L4-L5 degenerative spondylolisthesis with spinal stenosis and bilateral radiculopathy PROCEDURE PERFORMED: L4-L5 posterior lumbar interbody fusion (PLIF) with bilateral pedicle screw instrumentation INDICATIONS: 58-year-old male with progressive bilateral leg pain, neurogenic claudication, and MRI-confirmed L4-L5 stenosis with Grade 1 spondylolisthesis. Failed 6 months conservative management. Neurological examination shows L5 distribution weakness (4/5 EHL bilaterally). Patient consented for decompression and fusion. NEUROMONITORING: SSEP and MEP monitoring throughout - no changes POSITION: Prone on Jackson table with appropriate padding PROCEDURE DETAILS: Midline incision made from L3 to S1. Dissection carried through subcutaneous tissue and fascia. Subperiosteal dissection of paraspinal muscles bilaterally exposing L4 and L5 laminae and facets. Fluoroscopy confirmed appropriate levels. Pedicle screws placed bilaterally at L4 and L5: - L4: 6.5mm x 45mm bilaterally (medial wall intact on palpation) - L5: 7.0mm x 45mm bilaterally (medial wall intact on palpation) All screws had good purchase and no neuromonitoring changes. L4-L5 bilateral laminectomy performed with Kerrison rongeurs. Ligamentum flavum removed. Bilateral facetectomies performed preserving pars interarticularis at L4. Neural decompression completed: - L5 nerve roots decompressed bilaterally in lateral recess and foramen - Dural sac well-decompressed - No dural tears - Pulsatile dura and nerve roots after decompression Discectomy performed at L4-L5 bilaterally. Disc space prepared with shavers and curettes. Endplates decorticated to bleeding bone. Interbody cages placed: - 11mm PEEK cages filled with local autograft and allograft - Bilateral cages at L4-L5 with good positioning on fluoroscopy Rods placed bilaterally: - 5.5mm titanium rods contoured to lumbar lordosis - Set screws tightened, compression applied across L4-L5 Posterolateral fusion bed prepared with decortication of transverse processes. Additional autograft and allograft placed posterolaterally. Wound irrigated copiously. Hemostasis achieved. Vancomycin powder applied. Fascia closed with 0-Vicryl. Subcutaneous tissue with 2-0 Vicryl. Skin with 3-0 Monocryl subcuticular and Dermabond. ESTIMATED BLOOD LOSS: 300 mL DRAINS: None SPECIMENS: None COMPLICATIONS: None DISPOSITION: Patient tolerated procedure well. Neuromonitoring stable throughout. Transferred to PACU extubated. Post-operative neurological exam: Moving all extremities, sensation intact. Log-roll precautions. Physical therapy consult. Target discharge post-op day 2.
Intelligent ICD-10 Suggestions
PatientNotes suggests the codes most commonly used in neurosurgery
M51.26Other intervertebral disc displacement, lumbar regionM48.06Spinal stenosis, lumbar regionM54.16Radiculopathy, lumbar regionD33.0Benign neoplasm of brain, supratentorialS06.30Focal traumatic brain injury, unspecifiedG95.20Unspecified cord compressionI67.1Cerebral aneurysm, nonrupturedM50.22Other cervical disc displacement, mid-cervicalAI suggests relevant codes based on your documentation—review and select with one click.
Frequently Asked Questions
Can PatientNotes document complex spine surgery operative notes?
Yes. PatientNotes creates comprehensive spine surgery operative notes including levels operated, approach (anterior/posterior), decompression performed, instrumentation details (screw sizes, rod diameter), graft material, neuromonitoring data, and surgical findings.
Does PatientNotes handle neurological examination documentation?
Yes. PatientNotes documents detailed neurological exams including cranial nerves, motor strength by muscle group, sensory examination, reflexes, coordination, and gait. It uses standardized grading (0-5 motor scale) and dermatomal patterns.
Can I document cranial procedures and brain surgery?
Yes. PatientNotes has templates for craniotomy, craniectomy, tumor resection, and other cranial procedures including positioning, approach, brain relaxation, microsurgical technique, neuronavigation use, and closure details.
How does PatientNotes handle imaging review documentation?
PatientNotes documents MRI and CT findings with detailed descriptions of pathology location, size, characteristics, mass effect, and relationship to critical structures. It integrates imaging findings with clinical presentation.
Operate More, Document Less
Join neurosurgeons saving 2+ hours daily on documentation. PatientNotes handles the charting so you can focus on your patients.
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