Surgical H&P Note: Template, Example and How AI Drafts It
A surgical H&P (history and physical) is the pre-operative note that documents why a procedure is indicated, the patient’s history and exam, perioperative risk, and the plan, including consent. MD Record AI drafts it from the recorded consultation using the built-in H&P template or your own surgical template, for the surgeon to review and sign.
Last reviewed October 6, 2026
What a surgical H&P includes
- Chief complaint and surgical indication
- History of present illness, including prior treatment and imaging
- Past medical and past surgical history, with prior anesthesia problems
- Medications, including anticoagulants and antiplatelets, and allergies
- Family history of anesthesia complications or bleeding disorders
- Social history: tobacco, alcohol, functional status
- Review of systems, focused on cardiopulmonary risk
- Physical exam, including airway and the operative site
- Relevant labs, ECG and imaging
- Assessment, planned procedure, risks and alternatives discussed, consent and perioperative plan
A short fictional example
Fictional, to show the structure only. Not a real patient or real output.
CC / indication: 46-year-old with recurrent right upper quadrant pain after fatty meals. Ultrasound shows cholelithiasis without cholecystitis.
PMH / PSH: Hypertension. Appendectomy at 19, no anesthesia complications. Meds: amlodipine. No anticoagulants. NKDA.
Social: Non-smoker, occasional alcohol. Walks 30 minutes daily without symptoms.
Exam: BP 134/82. Airway Mallampati II. Lungs clear, regular rhythm. Abdomen soft, mild RUQ tenderness, negative Murphy sign.
Assessment / plan: Symptomatic cholelithiasis. Laparoscopic cholecystectomy discussed, including risks, benefits and alternatives; patient agrees. Pre-op labs. NPO after midnight.
Drafting it with an AI scribe
Record the pre-op consultation, or upload the audio, and choose the Initial Consultation H&P template. On Pro and Enterprise you can build a surgical H&P template with the exact sections above, so every draft comes out in your order.
Items that are rarely said out loud, such as ASA class or the consent discussion, should be added or confirmed by the surgeon. Macros (dot-commands such as .consent) insert standard wording in one step.
Every note MD Record AI generates is a draft. The treating clinician reviews, edits and signs it before it becomes part of the patient record.
Frequently asked questions
What is a surgical H&P?
The pre-operative history and physical: indication, history, exam, perioperative risk and the planned procedure, documented before surgery.
How is it different from a general H&P?
It adds the surgical indication, prior anesthesia history, anticoagulant use, airway and operative-site exam, and the consent and perioperative plan.
Can AI write my surgical H&P?
It can draft it from the recorded consultation in your template. The surgeon reviews, completes and signs it before it enters the record.
Can I use my own surgical H&P format?
Yes. Custom templates on Pro ($19/month) and Enterprise ($49/month) let you define the sections, and you can generate a template from a photo or PDF of your current form.