Anesthesiology AI scribe 2026: pre-op evaluation, anesthesia record, regional blocks, pain service, and the AQI reality

May 8, 2026 · 6 min read

Anesthesiology documents across four distinct workflows: pre-anesthesia evaluation (PAE) with risk stratification, the intra-operative anesthesia record (typically continuously generated by the EHR/AIMS), regional and neuraxial block procedure notes, and acute pain service follow-up for inpatients. The Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) collects detailed data for benchmarking.

The 2026 anesthesia-aware AI scribe stack handles four things: pre-op evaluation with ASA status + airway assessment + risk-specific elements, regional / neuraxial block procedure notes, acute pain service rounding, and AQI NACOR field population.

Pre-anesthesia evaluation

The PAE structure includes:

• Procedure planned + indication
• Anesthetic plan (general / regional / neuraxial / MAC / combined)
• Allergy history + reactions
• Medical history with risk-relevant detail (cardiac, pulmonary, hepatic, renal, metabolic, neurologic)
• Anesthesia history (problems, family history of MH, etc.)
• Current medications + held meds for surgery
• NPO status
• Physical exam: vitals, airway (Mallampati, neck mobility, mouth opening, dentition, beard), heart, lungs
• Labs / EKG / other studies as indicated
• ASA Physical Status
• Surgical risk stratification
• Informed consent for anesthesia

The anesthesia system prompt

You are documenting an anesthesiology encounter.

OUTPUT structured note based on visit type:

For pre-anesthesia evaluation:
1. Procedure planned with surgical risk category
2. Anesthetic plan (with rationale)
3. Allergies
4. PMH + cardiac risk factors (RCRI elements)
5. Pulmonary status (smoking, asthma, OSA with STOP-BANG, COPD)
6. Other system review (hepatic / renal / DM / MSK / neuro)
7. Anesthesia history (PONV, MH risk, difficult airway, neuraxial complications)
8. Current meds with hold instructions
9. NPO status
10. Vitals + airway exam (Mallampati, mouth opening cm, neck extension, dentition)
11. Cardiac / pulmonary auscultation
12. Labs / EKG / TTE if obtained
13. ASA Physical Status (1-6 with E modifier)
14. Risk discussion + informed consent documented (cite transcript)
15. Plan of anesthesia + back-up

For regional / neuraxial block:
1. Indication + surgical procedure
2. Patient positioning
3. Skin prep + drape
4. Ultrasound / nerve stimulator guidance
5. Block performed (anatomic name with side)
6. Local anesthetic: agent, concentration, volume, additives
7. Needle type + depth + paresthesia / motor response
8. Successful block (sensory + motor confirmation)
9. Complications (vascular, intraneural, hematoma, LAST)
10. Catheter placement if applicable

For acute pain service rounding:
- Per-patient: visit purpose, current PCA / epidural / block
- Pain scores at rest + activity
- Side effects (nausea, sedation, pruritus, motor block)
- Plan adjustments
- Transition planning

Cite transcript or pre-op data. For ASA Physical Status, ensure justification is documented.

AQI NACOR registry alignment

The Anesthesia Quality Institute collects data per case for benchmarking. Documentation should populate AQI fields directly: ASA, anesthesia type, complications by NACOR category, blood loss, transfusion, intra-op events. Structured AI scribe output reduces abstraction burden.

Vendor and DIY paths

For anesthesiology groups, integrated AIMS (Anesthesia Information Management Systems) like Epic Anesthesia, AIMS-Plexus, others handle the intra-op record continuously. The AI scribe is most useful for pre-op evaluation, block procedure notes, and acute pain service rounding — voice-driven structured documentation that complements the AIMS.

BAA chain

Anesthesia group + hospital + AIMS + transcription vendor + LLM vendor.

When to start

For anesthesia practices doing high-volume regional blocks, the structured block procedure note saves dictation time and improves billing accuracy for separately-billable blocks. Pre-op evaluation structured documentation supports faster pre-op clinic throughput.