Adding clinical notes using templates
Using a clinical note template as a guide, you can quickly and accurately document a patient's visit with minimal typing or editing. 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.
Note: A clinical note was automatically started when information was entered into a patient health assessment and/or a medical history review.
To add a clinical note using a template
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.
· If a clinical note page is not selected when you choose a template, a new clinical note will be added. So, to add a template to an existing note, make sure the correct page of that clinical note is selected.
· 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.
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. In the template pane (on the right), expand a category to view the list of available templates for that category by clicking the plus sign (+) next to the category name, and then locate the template that you want to use.
4. Double-click the desired template.
Messages appear and prompt you for responses if the template requires them; otherwise, the template text is automatically entered into the note field (in the middle), and you can skip step 5.
5. Respond to the prompts associated with the template, if applicable.
The template text is automatically entered into the note field (in the middle).
Note: If a prompt is named "Assessment" or "Plan," the information entered can appear in exported C-CDA documents in an "Assessments" or a "Planned Care" section.
6. After entering a clinical note using a template, you can edit the note or add additional information as needed.
7. Click the Save Clinical Note button to save the note. If a certain clinic setting is enabled, the default name of the note ("Note#") is changed to the category and name of the template that was used to create the note (if multiple templates were used to create the clinical note, the category and name of the first template used is used).
Note: The note is automatically saved if you go somewhere else in the program or close the Patient Chart.