PatientTrac Surg + PatientTrac Ambulatory

Surgical Intelligence

One surgical platform. Two connected workflows.
PatientTrac Surg delivers AI-assisted, clinician-reviewed surgical documentation, smart consent, standards-based coding, and recovery tracking. PatientTrac Ambulatory extends the platform into surgery centers and operating rooms with case flow, room utilization, and perioperative coordination.

7Shipping specialties
2Connected apps
AIAssistive documentation
837PStandards-based claims
Two Applications · One Surgical Ecosystem

Built for the Complete Surgical Journey

PatientTracSurg.com markets two distinct products: the surgeon-facing documentation platform, and the surgery-center operating-room workflow application.

PatientTrac Surg

AI-assisted surgical documentation

For surgeons and specialty practices that need faster, cleaner, more complete clinical documentation with smart consent, standards-based coding, and specialty-specific workflows. This is the app on this page.

  • Procedure documentation
  • Smart consent management
  • AI operative-note drafts
  • CPT / ICD-10 coding support
  • Revenue-cycle workflows
  • Recovery tracking
Explore PatientTrac Surg

PatientTrac Ambulatory

Surgery-center and operating-room workflow

A separate product for ASCs, surgical centers, OR managers, and perioperative teams that need visibility across rooms, cases, staff, and facility-level performance. Available at patienttracor.com.

  • OR scheduling
  • Room utilization
  • Case status dashboards
  • Team coordination
  • Pre-op to post-op flow
  • Facility analytics
Explore PatientTrac Ambulatory
AI Documentation Layer

Assistive Intelligence, Clinician-Reviewed

Every AI feature drafts, summarizes, suggests, or flags for clinician review. API keys stay server-side in Netlify Functions and never reach the browser, and PHI is stripped before AI calls. Clinicians make every clinical and coding decision.

Operative-Note Drafting

Server-side, streaming draft operative notes from structured case data, plus dictation cleanup and note review. Drafts are starting points the surgeon edits and signs.

Coding Suggestions

Suggested ICD-10 and CPT codes with RVUs, modifiers, and laterality for the clinician to confirm. Suggestions support documentation completeness — they never determine or guarantee reimbursement.

Safety & Risk Flags

Drug-interaction checking and risk scoring run server-side to surface surgical safety flags for the care team. Alerts inform clinicians; they do not diagnose or decide.

Registry Extraction

Assistive extraction of structured fields for registries such as NSQIP, MBSAQIP, NCDR CathPCI, and STS — designed to reduce duplicate abstraction while keeping a human in the loop.

Shipping Specialty Modules

Seven Specialties, Documented in Depth

Each shipping module maps a real surgical workflow — from pre-procedure evaluation through the operative record to recovery — with validated clinical scores, specialty classifications, and coding support.

Cardiac · Interventional / Cath Lab

Interventional Cardiology

Cath-lab documentation for interventional cardiology — not open-heart surgery — from pre-procedure through hemostasis and discharge.

Capabilities
  • Pre-procedure: hemodynamics, coronary anatomy, planned intervention
  • Post-procedure: access-site hemostasis, DAPT plan, discharge
  • AI op-note templates for Diagnostic Cath and PCI
  • Assistive registry extraction (NCDR CathPCI, STS Adult Cardiac)
Validated scores & tools
GRACEHEARTNCDR CathPCISTS Adult Cardiac
Revenue & coding

Coding support for interventional/cath procedures with modifier and documentation-completeness checks.

Dermatology

Dermatologic Surgery

Procedure documentation with interactive lesion mapping and standardized photo capture for skin surgery.

Capabilities
  • Interactive lesion mapping on a body diagram
  • Standardized photo documentation (6 views)
  • Pathology and specimen tracking
  • Excision, Mohs, biopsy, cryo, electrosurgery, laser, intralesional
  • AI templates for Skin Lesion Excision and Mohs
Validated scores & tools
Breslow depth6-view photo protocol
Revenue & coding

Excision- and Mohs-aware coding support tied to lesion size, site, and specimen documentation.

Endoscopy / GI

Endoscopy & GI

Structured endoscopy reporting with a built-in quality-metrics dashboard for GI programs.

Capabilities
  • Full report: pre-procedure, procedure, findings & polyps, pathology, post
  • Quality dashboard: ADR, cecal intubation rate, withdrawal time, prep rate
  • Classifications: Paris, Kudo, NICE; Boston Bowel Prep Scale
  • AI templates for Colonoscopy with Polypectomy and EGD
Validated scores & tools
ParisKudoNICEBoston Bowel Prep
Revenue & coding

Supports quality and value-based reporting (GIQuIC-style) alongside procedure coding capture.

Ophthalmic

Ophthalmic Surgery

End-to-end ophthalmic surgical documentation with rigorous laterality and biometry handling.

Capabilities
  • Surgery: pre-op, visual acuity, biometry & IOL, procedure, consent, post-op
  • Post-op: VA, refraction, exam, complications, follow-up
  • Laterality (OD/OS) with LT/RT coding modifiers
  • AI templates for Phaco with IOL and Pars Plana Vitrectomy
Validated scores & tools
LOCS IIIIOL biometry constantsOD / OS
Revenue & coding

Laterality-aware coding support (LT/RT modifiers) to keep eye-specific claims documentation complete.

Orthopedic

Orthopedic Surgery

Evaluation to operative note to recovery, with PROMs and implant tracking built in.

Capabilities
  • Eval: history/exam, ROM, strength, special tests, PROMs
  • Op note: approach, findings, implants, closure
  • Post-op: weight-bearing, restrictions, therapy, follow-up
  • Implant tracking that feeds implant charge capture
  • AI templates for TKA and ACL Reconstruction
Validated scores & tools
Caprini VTEKOOSHOOSPROMIS
Revenue & coding

Implant tracking connects to implant charge capture so device documentation supports the claim.

Anesthesiology
Anesthesiology

Anesthesiology

The deepest module: one anesthesia record per case spanning pre-op, intra-op, and PACU, plus nine procedure-specific extensions.

Capabilities
  • Pre-op: ASA & airway, Mallampati, history, plan, clearance
  • Intra-op anesthesia record
  • PACU discharge: Aldrete, PONV, drug-interaction review
  • Nine procedure-specific anesthesia extensions
  • Time-based anesthesia billing calculator
  • Server-side drug-interaction decision support and risk scoring
Validated scores & tools
ASASTOP-BANGRCRIMallampatiAldrete
Revenue & coding

Time-based anesthesia units calculator supports accurate, documentation-backed anesthesia billing.

General Operative

General Surgery

The general operative core: surgeon exam through operative note, with a Universal Protocol time-out and a surgical drawing tool.

Capabilities
  • Surgeon exam: history/assessment, procedure planning, clearances/labs, pre-op instructions
  • Operative note: diagnosis/procedures, operative details, findings/specimens, closure
  • Universal Protocol time-out checklist
  • Surgical drawing tool with specialty templates
  • Server-side AI op-note drafting (streaming), note review, code suggestion, safety flags
Validated scores & tools
Caprini VTEUniversal Protocol
Revenue & coding

AI code suggestion and pre-submission checks help keep operative documentation and claims complete.

PatientTrac · Anesthesiology

Anesthesia Intelligence

Pre-op to PACU, one anesthesia record.
AI-assisted pre-operative airway and risk assessment with ASA, STOP-BANG, and RCRI scoring, a structured intra-operative anesthesia record, and PACU recovery tracking with Aldrete discharge scoring — extended by nine procedure-specific anesthesia verticals. All scores inform the clinician; they never decide.

9Procedure extensions
5Validated scores
3Pre → Intra → PACU
CDSServer-side drug checks
Revenue-Cycle Workflows

Standards-Based Claims, End to End

Capture, validate, and submit with standards-based tooling. Nothing here guarantees payment — the goal is complete documentation and clean, standards-compliant claims that give payers what they need.

Capture & Coding

Structured CPT/ICD capture with AI coding suggestions for clinician review.

  • RVUs, modifiers, laterality
  • Implant charge capture
  • Anesthesia time-units

Validate & Submit

Standards-based X12 837P generation with superbill and EDI submission.

  • 837P claim generation
  • Superbill + EDI submission
  • Denial-prevention validation (pre-submission checks)

Verify & Estimate

Insurance verification and a patient-responsibility calculator for transparent estimates.

  • Insurance verification
  • Patient-responsibility calculator
  • Designed to reduce avoidable claim rejections
Platform & Security

Built on Concrete Safeguards

We describe the mechanisms we implement — not compliance labels. Security is enforced in the architecture, from the database row up.

Data Protection

  • Row-Level Security on all clinical tables
  • Org-level tenant isolation
  • PHI stripped before AI calls

Access & Keys

  • TOTP multi-factor authentication
  • API keys held server-side (Netlify Functions)
  • AI audit log (encounter_id + function only)

Consent & Records

  • Smart consent: e-signature, multilingual, audit trail
  • Surgical vs anesthesia consent kinds + consent tokens
  • Equipment/implant lot, serial, expiry & sterilization log
The Clinical Intelligence Network

Connected Across the PatientTrac Network

PatientTrac Surg is a member of the PatientTrac Clinical Intelligence Network. Clinicians can launch a surgical encounter directly from other network apps on a shared record.

Cross-App Encounter Launch

Route into surgery from Forge, Revela, or Mind with checkin_and_route and a short-lived, cross-app JWT — all on the shared encounter_id.

Shared Clinical Viewer

A shared clinical-viewer chart keeps the same patient context visible as the encounter moves between network apps.

One Encounter Identity

Because the network shares a single encounter_id, surgical documentation joins the broader clinical story instead of living in a silo.

On the Roadmap

Coming to the Network

These specialties are planned, not yet shipping. They do not have dedicated documentation modules today — we are being upfront about what is live versus what is on the way.

Planned

Bariatric

Bariatric-specific documentation is on the roadmap. No dedicated bariatric module ships today.

Planned

Plastic & Reconstructive

Plastic and reconstructive workflows are planned for a future release, not currently available.

Planned

Oral & Maxillofacial

Oral and maxillofacial documentation is on the roadmap and not a shipping module at this time.

Performance and ROI figures referenced anywhere on this page are internal design goals and projections, not measured or guaranteed outcomes.

Complete Surgical Lifecycle

From Documentation to Recovery

01Schedule
02Intake
03Consent
04Document
05Operate
06Recover
07Analyze

One Platform. Two Workflows. One Network.

See PatientTrac Surg for surgeon documentation, or PatientTrac Ambulatory for surgery-center and operating-room workflow — both part of the PatientTrac Clinical Intelligence Network.