Trusted from independent practice to national hospital groups
The neurological baseline, the risks you disclosed and the operation note element by element, Note Dr writes the spinal record, ready to approve.
Get Note Dr free→Trusted from independent practice to national hospital groups
Note Dr listens to the consultation as it happens. While you examine the patient, talk through the procedure and disclose the material risks, it writes the record in the background, so a patient weighing up spinal surgery gets you, not the top of your head over a keyboard.
Material risks disclosed, in their words
The specific warnings Montgomery requires, recurrence, dural tear, nerve injury and cauda equina, with the reasonable alternatives, captured in the patient's own context the moment you take consent, not paraphrased on a generic form.
The neurological baseline on record
Power, sensation, reflexes and straight leg raise documented before surgery, the deficit you start from, captured as you examine so any post-operative change is measured against a clear baseline.
The operation note, element by element
Findings, neuromonitoring, any implant and its serial number, closure, blood loss, complications and prophylaxis, the RCS elements audits show drop most, recorded contemporaneously so the note matches the procedure.
A reviewed Note Dr record captures more of what a record needs to stand up to scrutiny in spinal surgery, the Montgomery consent, the operation note elements and the continuity of care, where published standards and audits show conventional records routinely fall short.
Standards and audits referenced: RCS England Good Surgical Practice (2025), Montgomery v Lanarkshire Health Board (2015), GMC Good Medical Practice (2024), with operation-note and consent audits (Singh et al, 2012; Tonge et al, 2021).
Ask what the neurological examination showed, which material risks you disclosed, or exactly what the patient consented to, answered in seconds from their own record.
Walk into theatre already knowing the story, without trawling the notes.
When a case calls for it, Note Dr surfaces the published guidance behind your decisions, the RCS England Good Surgical Practice operation-note standard, GMC Good Medical Practice and consent guidance, the principles of Montgomery, the WHO Surgical Safety Checklist and NatSSIPs, and PRSB record-structure standards, with the source cited. It never tells you how to treat your patient; that judgement stays with you.
Want me to surface any guidance for this? You could ask:
Why spinal surgeons trust Note Dr with a record that stands up to scrutiny.
★★★★★
Every material risk, in the note
Recurrence, dural tear, nerve injury, cauda equina, the specific Montgomery risks I disclose are captured in the patient's own context, not paraphrased on a form. For elective spinal surgery where consent is everything, the discussion is always there in black and white when records are reviewed.
★★★★★
The operation note is finally complete
Findings, complications, blood loss, prophylaxis, the RCS elements that used to get dropped at the end of a list are all there. The neuromonitoring and the fact the dura was intact is documented as I operate, so the note matches what I actually did.
★★★★★
The neuro baseline is never missed
Power, sensation, reflexes, straight leg raise, the deficit I start from is logged before surgery every time. When I review a patient post-operatively, any change is measured against a clear baseline in the record rather than my memory of clinic.
★★★★★
Hands stay on the patient
Someone weighing up spine surgery does not want me typing through their consent. Now I examine, explain the procedure, disclose the risks and reassure, and the clinic note is still written. It has genuinely changed how my pre-operative clinics feel.
★★★★★
Calmest case review we have had
Assessment, Montgomery consent and the operation note, complete on every case across the team. Our last record-keeping review against Good Surgical Practice was the smoothest we have run, the notes already told the whole story from consent to discharge.
Every recording and record is protected by strong, independently assessed security and encryption.
★★★★★
My records have never been this thorough: the neurological baseline, the material risks disclosed under Montgomery, the operation note element by element and the recovery, the lot. For the first time I would hand a court the full file on any case I have done and trust it to speak for itself.
Miss Carys CConsultant spinal surgeon
Record each material risk individually, recurrence, dural tear, nerve injury, infection and the rare risk of cauda equina, alongside the reasonable alternatives such as continued non-surgical care, and the patient's decision. Note Dr captures the key points of the discussion in the patient's own context as you take consent, ready for you to approve.
Yes. It drafts the named elements as you work: the findings and any complications, tissue removed, any implant and serial number, closure, estimated blood loss, antibiotic and VTE prophylaxis and post-operative instructions. When the note is written up hours after the list, this housekeeping slips the mind, not the decompression itself. You review and approve the note before it is saved.
Note Dr captures the pre-operative neurological examination as you assess the patient — power, sensation, reflexes and straight leg raise, and any motor deficit such as reduced ankle dorsiflexion. Recorded before surgery, that baseline becomes the reference any post-operative change is measured against, rather than your memory of clinic. You review and approve every note before it is saved.
Note Dr does not connect to your electronic patient record by design; you copy or export the finished note and paste it wherever the record lives. That keeps it usable across NHS and independent systems without an integration project, and means nothing reaches the record until you have reviewed and approved it. The transcription itself runs on your own device.
Note Dr drafts the record for cervical, thoracic and lumbar procedures alike — from an anterior cervical discectomy and fusion to a lumbar microdiscectomy or decompression. You can build a custom template per procedure, so the fields you need — myelopathy signs, implant details or fusion imaging — appear every time. You review and approve the drafted note.
Note Dr records the cauda equina safety-netting you give — the saddle-anaesthesia, bladder, bowel and sexual-function warning signs, and your instruction to seek urgent review — as part of the consultation or discharge note. Documenting that you warned the patient, and exactly what you told them to watch for, supports a defensible record. It drafts the note; you review and approve it.
Note Dr documents the complication factually as it happens, an unintended dural tear and its repair, for example, so the operation note reflects exactly what occurred. A contemporaneous, accurate record supports the open conversation the GMC duty of candour expects. The clinical and candour actions remain entirely yours.