Vet AI Scribe for High-Volume Spay/Neuter

On a full surgery day every op note should read the same. Dictate intake, anesthesia and surgery as you go, and PawfectNotes fills in your clinic's template, with your standard findings wherever nothing was different.

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What PawfectNotes Does for High-Volume Spay/Neuter

Intake + Anesthesia Report
Intake, pre-op exam, the medications given and the anesthetic protocol in one report for each patient.
Op notes from your template
Build custom templates for your standard spay and neuter write-ups, with your usual findings set as defaults. Say what was different and the note records it.
The same note from every surgeon
Save the template as Practice and every surgeon and technician on the account writes up procedures the same way.
Discharge instructions
Discharge Note and SOAP + Discharge write the post-op instructions that go home with each patient, for owners, fosters or trappers.

Ready-made templates in the PawfectNotes library

Intake + Anesthesia Report
Discharge Note
SOAP + Discharge
Formatted Dictation
SOP Builder
Meeting Summary

Choose one in Templates before you record, or build your own.

Example Medical Records

Practice types & roles

Mobile Vet Relief Vets Telemedicine Urgent Care Mixed Animal & Rural Practice Referral & Specialty Hospitals High-Volume Spay/Neuter Corporate & Multi-Site Groups Veterinary Technicians & Nurses Veterinary Students & New Grads

High-Volume Spay/Neuter

TNR 26-1184 (community cat, female)

Wednesday, October 14, 2026 at 8:20 AM

Spay day · Intake + Anesthesia Report and surgery record

Intake

Brought in by a trapper in a covered live trap.
Estimated age: 1–2 years (adult teeth, minimal tartar)
Weight: 2.9 kg (in trap, trap weight subtracted)
No ear tip, no tattoo; no microchip on scan.
Pre-op exam (in trap, completed after induction): Body condition 4/9. Mucous membranes pink. No nasal or ocular discharge. Flea dirt present. Heart and lungs normal. Mammary glands not developed; not lactating. No palpable abnormalities.

Anesthesia

8:32 AM — TKX (clinic standard mix) 0.25 mL IM through the trap divider. Buprenorphine 0.06 mg IM (0.02 mg/kg).
Eye lubricant applied. Oxygen by mask at 1 L/min; not intubated.
Monitoring every 5 minutes: Heart rate 160–180 bpm, SpO2 95–98%, respiratory rate 16–24 breaths/min.
Warming pad throughout. Temperature at the end of surgery: 98.9°F.
Meloxicam: 0.6 mg SC (0.2 mg/kg) at the end of surgery.

Surgery

Procedure: Ovariohysterectomy, ventral midline.
Time: 8:44 to 8:53 AM.
Findings: Uterus normal size; not pregnant; no evidence of pyometra. Both ovaries removed intact.
Ligation: Ovarian pedicles autoligated; uterine body ligated with 3-0 absorbable suture.
Closure: Linea alba 3-0 absorbable, simple continuous; intradermal 4-0 absorbable; tissue adhesive.
Ear tip: Left ear, about 1 cm removed straight across.
Tattoo: Green line tattoo beside the incision.
Also given under anesthesia: FVRCP SC, rabies SC (right hind limb), topical flea treatment.
Complications: None.

Recovery

Recovered in the covered trap. Sternal at 9:30 AM; head up and alert at 10:05 AM.

Discharge Instructions for the Trapper

Keep her in the covered trap overnight in a quiet, warm indoor space.
Offer a small amount of wet food this evening.
Release at the trapping site tomorrow morning (Thursday, October 15) if she is alert and has eaten.
All sutures are absorbable; nothing needs removing.
Call the clinic before release if there is bleeding from the incision, she has not eaten, or she seems unsteady.

— Surgeon: Dr. Elena Varga, DVM · Anesthesia: Sam Chu, LVT

High-Volume Spay/Neuter FAQ

Can every surgeon's notes follow the same format?

Yes. Make one custom template, save it as Practice, and everyone on the practice account can use it.

Can my standard findings go in without me saying them?

Yes. Set your usual findings as defaults in the template; anything you say that differs replaces them. Review each note before you sign it, because a default you didn't change will still be in the record.

Can technicians record the intake?

Yes. Support staff accounts are always free. A technician records for the surgeon, and the note is saved as the surgeon's note.