Working with Clinical Notes

Adding Clinical Notes at the End of the Day

If you prefer not to enter clinical notes at the time of the procedure, you can enter them later using the End of the Day clinical notes feature.

 

To configure the software to enable you to add clinical notes to all charts at the end of the day, select Add Clinical Notes at End Of Day in the Chart Options Properties window. See Setting Charting Options and Properties.

 

To post an end of day clinical note regardless of how you have configured the software, select List > Post End of Day Notes.

To add clinical notes at the end of the day:

  1. Chart and post a procedure. Any time after posting the procedure, select an option:

  2. While on the Restorative, Exams, Clinical Imaging, or Treatment Planning tab in the chart:

  3. While on any tab in the chart:

OR

Select List > Post End of Day Notes.

 

The Work Performed window is displayed. All actual and treatment plan procedures for the current date and providers that do not have notes are displayed in the list.

To display procedures for a previous date, click the drop-down arrow in the Work Date field and select the date.

  1. Select an option:

  2. To display a list of current and treatment plan work that does not have a note associated with it:

  3. To display a list of current and treatment plan work that has notes associated with it:

  4. To display current and treatment plan work for a specific provider:

  1. Select the procedure and click Add/Edit Note. The Patient Clinical Notes window is displayed.

  1. Type a brief description of the note's contents in the Re field. The text entered in this field is displayed in all clinical notes list windows.

  2. Complete the following information:

  3. Select the procedure code to which the note refers from the ADA Code drop-down list. You can select only a production or explosion code from the list.

  4. Select the condition from the drop-down list.

  5. Type the tooth and surface information in the fields, or click the drop-down arrows to select the information.

  6. Select the type of watch from the drop-down list.

  7. Select the provider from the list. The provider does not affect the chart.

  8. Select Reviewed by Dr. to indicate the doctor has seen this note.

  1. Type text in the Note field.

  2. If you have the proper security permissions, you can edit this note after it is saved until the end of the day. After that time period, you can only amend the note.

  1. To use this note as a default when posting the procedure, check Use this text as the default for this ADA Code.

  2. Click OK. The current date is added at the end of the note. If no generic note is associated with the procedure code for the provider, a message is displayed. Click Yes to save the note as the generic note for the procedure.

  3. Click Close twice.