Related Training
Related Training
Using Clinical Notes Recorded Class
You can insert clinical notes into a current or previous date (day-based), or provide additional details to clinical events, using the Insert Note function in a patient's Hard Tissue Chart, Treatment Chart, Soft Tissue Chart, Perio Chart, Orthodontic Clinical Summary, and Treatment Plan windows.
A day-based clinical note does not have to coincide with an appointment. For example, you might insert one when a lab result is returned or a patient calls to report a clinical issue.
To insert a clinical note:
On the Patient tab, click Clinical and select a clinical view.
Locate the day for which the new note is required and click Insert Note. The Note for window is displayed.
Start typing to enter new free-form clinical note text, or select a clinical notes template to add pre-defined text into the note.
Only active templates are available for selection.
If you select a template, click Insert Text, and then edit the note as needed.
An oral surgery office might want to add a Completed Procedures, Completed Procedures Description, or Completed Procedures and Completed Procedures Description merge field to a template, rather than manually entering this information. When procedures are posted to a patient's account, they are automatically applied to the Completed Procedures merge fields in the template.
Click Save.
Tip: You can move the Note window around on the screen as you access other information pertaining to the patient.
To display clinical notes in the Hard Tissue Chart:
Click on the Diagonal Arrow icon in the upper-right of the clinical notes section of the chart.
The Notes window expands, allowing for greater visibility of the clinical notes.
To return to the regular chart view, click the icon in the upper-right corner of the expanded window to contract it or click in the background of the chart.
Doctors can sign clinical notes with a unique Personal Identification Number (PIN), for tracking and managing clinical notes. A Clinical Notes Worklist has been added to the Location > To Do menu, so that you can manage clinical notes entered for a selected day, obtain signatures, and create notes for clinical events that need them.
A PIN entry field has been added to the Team Member Settings (Administration > Team) for all users whose Role is defined as Doctor. This number is visible only to individual doctors, who set their own PIN by selecting User Menu > My Settings > Edit Selected Team Member. The PIN must be numerical with no letters or punctuation.
Administrators can see whether a doctor's PIN has been defined, but they cannot see or change a doctor's PIN.
A Save & Sign button is displayed on the Clinical Note window when creating a new note or editing an existing note.
A Sign button is displayed for existing notes not yet signed.
After entering or editing a clinical note, select Save &
Sign or Sign to display the Clinical
Note Approval window.
The Provider field defaults to the logged-in doctor, but other doctors can be selected from the list if a PIN is defined for them. When an eligible doctor is selected, the PIN field becomes active. The selected doctor can enter the PIN and click Sign.
When a clinical note is signed, the status Note Signed
is indicated in the Clinical Notes list and the note's
history.
Note: When a signed clinical note is edited, it must be signed again to acknowledge the changes.
Using the Clinical Chart (EMR)