Adding Clinical Notes Per Visit

You can enter all of the clinical notes associated with a visit at one time—when you close the patient chart—instead of entering a note after you post each procedure.

To configure the software to enable you to add per-visit clinical notes to a chart, select Add Clinical Notes Per Visit and Add Clinical Notes While Posting in the Chart Options Properties window. See Setting Charting Options and Properties.

To add all of the clinical notes for a visit after posting the procedure:

Post all procedures as you typically would and close the chart. The Add Clinical Notes For Visit window is displayed. More:

Each procedure checkbox is selected by default, unless the ADA code is not required to have a clinical note. (An ADA code is not required to have a note if you have selected the Never add a note option in the ADA/Transaction Codes window.)

If the code is set to Automatically add the default note or Manually add a note, and a default note exists for either all providers or the production provider for that code, the note is displayed in the Default Note column.

If no default note exists, the column displays a NO NOTE DEFINED - Doctor must add manually message.

Select the procedures to which you want to add clinical notes for this visit.
Click OK. The Patient Clinical Notes window is displayed.
Select an option:
Add a clinical note by highlighting the << Default Note not found. Please add a note here. >> text and typing the note.
Add to an existing note by typing in the area below the Tth-Surf/Quad line.

Use the scroll bar to view all of the procedures for the appointment.
Click OK.