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Surgical Documentation

Complete Surgery Reports in Minutes

Document procedures, anesthesia, findings, and post-op care in one structured report. Stop retyping the same details and let AI organize it.

No account required to try. Full editing control.

See What VetGeni Generates

Example surgery report from a foreign body removal

Example Output

Generated in 15 seconds

Patient and Procedure

Patient: Mia, 5-year-old female spayed German Short-Haired Pointer Procedure: Exploratory laparotomy with enterotomy (foreign body removal) Date: December 28, 2025

Patient Preparation

Placed in dorsal recumbency. Abdomen clipped from xiphoid to pubis with lateral extension to flank folds. Prepared with alternating chlorhexidine and alcohol scrubs, then final sterile prep with chlorhexidine solution and standard sterile draping.

Approach

Ventral midline skin incision from just caudal to the xiphoid to caudal to the umbilicus. Subcutaneous tissues dissected to expose the linea alba. Linea alba incised to access the abdomen, then contents examined for abnormalities.

Foreign Body Removal

Exploration identified an intestinal segment containing the foreign body. Segment exteriorized and isolated; stay sutures placed. Longitudinal enterotomy performed over the foreign body and sock removed. Enterotomy closed in a single-layer appositional pattern; mesenteric vessels ligated as indicated. Abdomen inspected to confirm no additional foreign material.

Closure and Comments

Linea alba closed with size 0 PDS in simple continuous pattern. Subcutaneous tissue closed with 2-0 Monocryl simple continuous. Skin closed with a skin stapler. Comments: No comments.

How It Works

Three steps to better documentation

1

Enter Procedure Details

Input patient info, procedure type, anesthesia protocol, and findings.

2

AI Structures Report

VetGeni organizes everything into a surgical documentation format.

3

Review and Finalize

Edit any section, add notes, then save to the patient record.

Complete Surgical Documentation

Anesthesia Monitoring

Pre-med, induction, maintenance, vitals, and recovery.

Procedure Templates

Common surgeries pre-structured for speed.

Surgeon and Assistant Roles

Document who did what in the OR.

Findings and Complications

Detailed operative notes with clarity.

Post-Op Orders

Meds, restrictions, and follow-up timing.

Export Options

PDF, print, or copy to your EMR.

Frequently Asked Questions

Can I save templates for common procedures?

Yes. Create templates for spays, neuters, mass removals, dentals, and more.

Does it include anesthesia monitoring?

Yes. Document pre-med, induction, maintenance, vital signs, and recovery notes.

Can multiple team members contribute?

Yes. Document surgeon, assistant, and anesthetist roles.

How detailed are the surgical notes?

As detailed as you need, from brief summaries to step-by-step descriptions.

Stop Spending 20 Minutes on Surgery Reports

Generate complete surgical documentation in minutes. Try free - no account needed.