The AI scribe for maxillofacial surgeons

From trauma to reconstruction

The facial trauma findings, the Montgomery consent and the operation note in full, Note Dr writes the whole maxillofacial record, ready to approve.

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From the trauma clinic to an approved note

Note Dr listens to the assessment as it happens. While you examine the injury, read the imaging and talk a frightened patient through the operation and its risks, it writes the record in the background, so they get a surgeon looking at their face, not the top of your head over a keyboard.

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Built for scrutiny

Defensible by
default, trauma to follow-up

  • The trauma findings, as you saw them

    The mechanism, the occlusion, the nerve deficit and what the CT showed, the baseline a facial injury is judged against, captured as you examine, not reconstructed from memory at the end of the list.

  • Montgomery consent, risk by risk

    The material risks you set out, nerve injury, infection, plate problems, malocclusion, scarring, and the reasonable alternatives discussed, logged in the patient's own context the moment you take consent.

  • The operation note, to the RCS standard

    Findings, the procedure, any extra step and why, the plate and screws used, closure, blood loss and prophylaxis, the narrative fields audits show go missing, documented contemporaneously so the operation note matches the procedure.

Document the mandibular fracture plan

Surgical plan, left angle fracture

Findings recordedDisplaced left angle, IAN deficit, malocclusion
Material risks explainedNerve injury, infection, plate, malocclusion, scar
Consent recordedORIF left angle, time to consider

Trauma to fixation, fully recorded

A reviewed Note Dr record captures more of what a record needs to stand up to scrutiny in surgery, the operation-note narrative the RCS sets out, the Montgomery consent discussion and the continuity from trauma to follow-up, where published standards and audits show conventional records routinely fall short.

  • Time back in your day
  • Burnout & wellbeing

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).

Documented from
trauma to follow-up

    Patient memory

    The whole case,
    before the trauma list

    Ask what the trauma examination found, what the CT showed, 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.

    Ask Note Dr, Caradoc Vellacott
    What did we find for Caradoc, and what did he consent to?
    NNote Drfrom this patient's record
    At the trauma clinic on 20 June, you found a displaced left mandibular angle fracture and an undisplaced right parasymphysis fracture on CT, with a left inferior alveolar nerve injury causing lip and chin numbness. You recommended ORIF of the angle, and consent was recorded for nerve injury, infection, plate problems, malocclusion, scarring and non-union.
    Drawn from 3 documents across 2 visits
    Clinical references

    The standard,
    at the trauma call

    When a case calls for it, Note Dr surfaces the published guidance behind your decisions, RCS England Good Surgical Practice and its operation-note standard, GMC Good Medical Practice, the consent principles set by Montgomery, the WHO Surgical Safety Checklist and the BAOMS and trauma guidance maxillofacial surgeons work to, with the source cited. It never tells you how to treat your patient; that judgement stays with you.

    app.notedr.com
    Appointment TranscriptCaradoc VellacottToday · 17:06
    06:18CaradocMy jaw doesn't meet right since I came off the bike, and the left side's gone numb.
    06:31SurgeonDisplaced left angle fracture on CT with an inferior alveolar nerve injury. We'll fix it with a plate, let me cover the risks.
    NNote Dr

    Want me to surface any guidance for this? You could ask:

    Show me the RCS operation-note standard in Good Surgical Practice
    What does Montgomery require me to document for consent?
    Remind me of the WHO Surgical Safety Checklist steps
    Find the guidance on managing mandibular angle fractures
    What should I record under the duty of candour for a complication?
    GuidelinesJournalsReferences

    Trusted in theatre and
    on the trauma round

    Why maxillofacial surgeons trust Note Dr with a record that stands up to scrutiny.

    ★★★★★

    The operation note is finally complete

    Mr Gethin P, consultant maxillofacial surgeon

    Findings, the extra procedure and why, the plate lot numbers, blood loss, prophylaxis, the narrative bits that always slipped when I dictated from memory are all captured as I operate. The note matches the RCS standard, and it's finished before the patient leaves theatre.

    ★★★★★

    Montgomery consent, named risk by risk

    Miss Saffron O, consultant OMFS surgeon

    Nerve injury, infection, plate problems, malocclusion, scarring, every material risk I set out is logged in the patient's own words without me thinking about it. For facial surgery where consent is everything, the discussion is always there in black and white.

    ★★★★★

    Trauma findings, captured at the bedside

    Mr Tobias R, maxillofacial trauma surgeon

    The mechanism, the occlusion, the nerve deficit, what the CT showed, it's all recorded as I assess in the trauma clinic. When a facial injury is reviewed months later, the baseline reads exactly as I found it, not as I half-remembered it.

    ★★★★★

    Complications and candour, on record

    Ms Imelda C, consultant maxillofacial surgeon

    When a nerve deficit is going to be permanent, the open conversation under the duty of candour is captured the moment I have it. The complication and what I told the patient sit in the record exactly as they happened, which matters most when the stakes are this high.

    ★★★★★

    The face gets my full attention

    Mr Lorcan F, consultant maxillofacial surgeon

    Someone facing surgery on their face doesn't want me typing. Now I examine, read the scan, explain and reassure, and the clinic note is still written. It has genuinely changed how my trauma clinics feel.

    Rated 4.7 out of 5 by maxillofacial surgeons from 69 reviews

    What's said in the surgery
    stays in the surgery.

    Every recording and record is protected by strong, independently assessed security and encryption.

    ISO 27001 Aligned Cyber Essentials GDPR Compliant ICO Registered NHS Compliant UKCA Medical Device HIPAA Compliant

    ★★★★★

    My records have never been this thorough: the trauma findings, the Montgomery consent, the operation note to the RCS standard, the complications and the follow-up, the lot. For the first time I'd hand a court the full file on any case I have done and trust it to speak for itself.

    Mr Ewan HConsultant maxillofacial surgeon

    Maxillofacial surgeon FAQs

    Does an AI scribe understand maxillofacial surgery terminology?

    Yes — Note Dr is designed for clinical vocabulary, including the language of maxillofacial surgery: bilateral sagittal split osteotomy, Le Fort I, coronectomy, ORIF of the mandible, the inferior alveolar nerve. Transcription runs on your device and the draft keeps your phrasing, so it reads as you described. You review and approve every note before it enters the record.

    Can Note Dr write an operation note to the RCS Good Surgical Practice standard?

    Yes. It drafts the full operation note as you work: the findings, the procedure, any extra step and why, the implants and their lot numbers, closure, estimated blood loss, antibiotic and VTE prophylaxis and the post-operative instructions. Dictated after a long trauma list, it is a lot number or an extra step that a tired memory drops, so the note is finished before the patient leaves theatre.

    How does it help me document consent after Montgomery?

    As you discuss the operation, Note Dr captures each material risk you name, nerve injury, infection, plate problems, malocclusion and scarring, alongside the reasonable alternatives and what mattered to the patient. It records the key points of the discussion contemporaneously, the standard Montgomery and the RCS expect, for you to review and approve.

    Can an AI scribe document an orthognathic surgery consultation?

    Yes. Note Dr drafts the orthognathic record during the consultation: the facial and occlusal assessment, the plan agreed with the orthodontist, and the consent discussion a bimaxillary osteotomy demands — nerve injury, relapse and the change in appearance they're choosing. You review and approve each note, so a decision made over months of joint clinics is documented at every step.

    Can an AI scribe document a third molar consultation?

    Yes. Note Dr documents the third molar consultation end to end: the assessment, the relationship of the roots to the inferior alveolar canal as you read the OPG or CBCT, the warnings you give for extraction or coronectomy — including altered sensation of the lip, chin and tongue — and the post-operative advice. On a busy dentoalveolar list, every note is drafted for your review and approval.

    Does it document facial trauma findings and the imaging?

    Yes. As you assess a facial injury, Note Dr records the mechanism, the occlusion, the nerve deficit, the soft-tissue injuries and what the CT showed, in your own words. The baseline is captured at the time, so when the injury is reviewed later the record reads exactly as you found it, not reconstructed from memory.

    How do Note Dr notes get into my hospital or practice system?

    Note Dr has no EHR integration by design: once you have reviewed and approved a note, you copy or export it into whichever system you are working in. For maxillofacial surgeons who move between the NHS trauma clinic, theatre and private rooms — often on different software — the approved record follows you rather than binding you to one system.

    Records ready for every trauma call

    Complete, watertight notes from the trauma clinic to follow-up: the findings, the Montgomery consent, the operation note and the complications, reviewed and approved by you. The hours back are the bonus.

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