Adding clinical notes
You can add clinical notes by typing them from scratch or by using a template. Once a clinical note has been signed or is in history, it cannot be edited or deleted. However, an addendum can be made to a clinical note in history.
· A clinical note was automatically started when information was entered into a patient health assessment and/or a medical history review.
· The clinical notes are arranged by date, note number, and then page. You can have as many notes as you want, with a maximum of 10 pages per note.
To add a clinical note
1. With a patient selected in the Patient Chart, on the File menu, click Clinical Notes.
The Clinical Notes window appears.
2. Do one of the following:
· Click the New Clinical Note button . The Change Date and Time dialog box appears. Leave the current system date and time entered, or specify a different date and/or time; and then click OK.
· If you want to add a page to an existing clinical note, expand the appropriate date and note in the left pane, and then click the New Clinical Note Page button . The Change Time dialog box appears. Leave the current system time entered, or specify a different time; and then click OK.
Note: A clinical note page that does not have a time/provider/clinic stamp is a clinical note that was converted from a version of Dentrix Enterprise prior to 5.0. Also, these older clinical notes will be attached to the patient's primary provider by default.
Depending upon certain global settings, before the note is added, the Edit Encounter Number dialog box will appear so that you can edit, type, or select an encounter number. Then, click OK.
One of the following occurs:
· The new note (Note#[number]) is listed under a date in the left pane. If you have a certain global setting enabled, the encounter number appears in square brackets (for example, ) after the note number.
· The new page (Pg[number]) is listed under the selected note (Note#[number]).
3. Type a note (up to 7,700 characters in length) you want to attach to this patient regarding an exam or treatment given. (The maximum length of a clinical note page is 8,00 characters, but 300 of those characters are reserved for the signature line that is added when a clinical note is signed.)
You can click the Check Spelling button to check the spelling of the note text (this button is available only if a certain preference setting has been enabled).
4. If you have the global setting enabled to display encounter numbers for clinical notes and need to change the encounter number for the selected clinical note (and all corresponding pages), there will be a Change Encounter for Selected Note button on the toolbar, which you can click to open the Edit Encounter Number dialog box and edit the encounter number.
5. If you need to assign a different clinic than the clinic currently selected for the clinical note, click the Change Clinic for Selected Note button to open the Select Clinic dialog box and select the appropriate clinic.
6. Click the Save Clinical Note button to save the note.
The note is automatically saved if you go somewhere else in the program or close the Patient Chart.
Tip: If you need to add additional information to an existing clinical note at a later date and time, insert your text cursor in the note field, click the Insert Date/Time button , and then begin typing the note. However, if the note is locked, you cannot change it, but you can add an addendum. (When a clinical note becomes locked is determined by a certain global setting.)