Writing clinical notes can be a time-consuming part of any doctor, assistant, or hygienist’s job. The note-writing process can go a lot faster if you use these two features in Dentrix: procedure notes and clinical note templates.
You can add procedure notes to individual procedure codes which can then be copied into the clinical note whenever that procedure code is set complete. This works best for procedures that don’t require different options or modifications and the standard note would apply to all patients. For example, taking a panoramic X-ray could utilize this type of note because that note will be written the same way for all patients who have that procedure completed.
In the Office Manager go to Maintenance > Practice Setup > Procedure Code Setup. Select a procedure category and a procedure code and click Edit. In the Procedure Code Editor window, select Edit Note and add the text of the note in the Procedure Code Progress Note field. When finished, select the Copy to Clinical Note option and click OK.
Whenever that procedure is completed, the text of your note will be copied into the clinical note in the Patient Chart. Simply copying a procedure note to a clinical note when it is completed is a great option for procedure codes that don’t require any changes to the way the note is written.
Clinical Notes and Templates
However, if there are variances in the way the note should be written, for example in the case of a procedure when one patient may require more anesthetic than another, I would recommend using clinical notes and templates in the Patient Chart. Using clinical notes is the best way to make clear, concise notes regarding how a patient was treated. You can write clinical notes in two ways: free-form, where you enter all the text for the note manually, or by using clinical note templates, where you are prompted to enter information specific to the procedures you complete. You can create and customize clinical note templates in the Patient Chart.
Although it may take some time to set up the templates initially, I believe they are well worth it! And once clinical note templates are set up, they will be available on all workstations in your office.
Writing clinical notes is so important to properly document the patient’s Chart. Make the process of writing accurate notes easier for your team by using the options Dentrix provides. My preference is using clinical note templates because of the prompts they can provide. These prompts help to eliminate any information being forgotten.
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By Charlotte Skagg, Certified Dentrix Trainer
Charlotte Skaggs is the founder of Vector Dental Consulting LLC, a practice management firm focused on taking offices to the next level. Charlotte co-owned and managed a successful dental practice with her husband for 17 years. She has a unique approach to consulting based on the perspective of a practice owner. Charlotte has been using Dentrix for over 20 years and is a certified Dentrix trainer. Contact Charlotte at [email protected]