Clinical data required for a complete note

What you put in is what you get

Morton doesn’t make up data: it writes from what you document. An empty section leaves a gap in the note; a well-completed section produces a more useful analysis and plan. That’s why it’s worth completing the case as thoroughly as you can before generating the prenote.

What each section asks for

The pre-anesthetic phase is organized into nine sections that follow the order of a medical history. Here’s what each one captures:

• Clinical case data: biological sex, age, weight and height, acceptance of blood products (all, some, or none), and, optionally, tags to identify the case.
• Procedures: the planned procedure, with its surgical technique, estimated duration, and additional information.
• Allergies: known allergies or adverse reactions, or a note that the patient denies any.
• Systems review: a review focused on what matters to the anesthesiologist (respiratory symptoms, chest pain, syncope, palpitations, or a history of malignant hyperthermia) and, in female patients, the obstetric and gynecologic history.
• Surgical history: the type of previous surgery, the type of anesthesia received, and the time elapsed since.
• Past medical history: underlying conditions, with their classification, control, complications, and systemic involvement.
• Tobacco, alcohol, and substances: use of tobacco, vapes, psychoactive substances, and herbal products (valerian, caffeine, green tea), among others.
• Objective: the physical exam, along with automatic calculations from weight and height (body mass index, ideal body weight, and lean body weight) and vital signs. The physical exam is documented with a note prefilled as normal (brief or extended) or customized system by system (airway, cardiovascular, respiratory, neurological, musculoskeletal, skin, and dental).
• Diagnostic tests: labs and studies (complete blood count, renal function, electrolytes, coagulation, and more), which you report one by one or all together in a free-text field.

What Morton generates from your data

Once you complete the sections, Morton builds two parts from that information:

• Analysis: the clinical interpretation of the case, with the risks relevant to anesthetic management.
• Anesthetic plan: the management recommendations Morton suggests for the case, which you can supplement with additional recommendations such as fasting, prophylaxis, ordering diagnostic tests, or reserving blood products or a step-down unit/ICU bed, among others.

Both are generated from what you documented, so the better the data, the better the result.

For a more complete note

• Complete every section before generating the prenote.
• Document in as much detail as possible: the analysis and the plan improve the more complete the previous sections are.
• Review and adjust the generated prenote before copying it into your medical record.