Signing clinical notes

You can review a clinical note in a patient's record and digitally sign the note to prevent it from being edited in the future.

Note:

• To sign a clinical note, the specified provider's or, if you are the provider, your user account must have a digital signature set up.

• You can also enter and sign clinical notes from the Clinical Note Tasks page.

To sign a clinical note

1. Do one of the following:

   • How to get there

     1. If the correct patient is not already selected, use the Patient Search box to access the patient's record.

        Note: You can include inactive patients in the search results by setting the Include inactive patients switch to On.

     2. On the Patient menu, under Clinical, click (or tap) Progress Notes.

        The patient's clinical record opens with the Progress Notes tab selected.

     On the Progress Notes tab of a patient's clinical record, the procedure history for the patient appears. Select a clinical note.

     

   • How to get there

     1. If the correct patient is not already selected, use the Patient Search box to access the patient's record.

        Note: You can include inactive patients in the search results by setting the Include inactive patients switch to On.

     2. On the Patient menu, under Clinical, click (or tap) Chart, Progress Notes, Quick Exam, Perio, or Tx Planner.

        The patient's clinical record opens with the Chart, Progress Notes, Quick Exam, Perio, or Tx Planner tab selected.

     On the Chart, Progress Notes, Quick Exam, Perio, or Tx Planner tab of a patient's clinical record, on the Clinical Notes menu, select a clinical note.

     

   The Clinical Note dialog box appears.

   

2. Review the note.

3. Edit and/or add to the note text, and change the other options as needed.

   Set up the following options:

   • Th - The teeth assigned to this note. Do one of the following if needed:

     • If no tooth numbers are assigned to the clinical note, to assign tooth numbers, click (or tap) the Assign teeth link, select the applicable teeth, and then click (or tap) X.

     • If tooth numbers are assigned to the clinical note, to modify the assigned tooth numbers, click (or tap) the link for those tooth numbers (such as 2-4). Select or deselect teeth, and then click (or tap) X.

     

   • Provider - The provider to associate with this note. Only providers who have access to the current location and who are flagged as charting providers are available. The exception to this is when a provider is associated with the clinical note and no longer has access to the current location; that provider is available in the list unless you select a different provider and then save the change.

   • Date - The date of the note. Click (or tap) the box to select a different date.

   • Additional Provider - A secondary provider (such as a hygienist) to associate with this note. Select a different provider or [None]. Only providers who have access to the current location and who are flagged as charting providers are available. The exception to this is when a provider is associated with the clinical note and no longer has access to the current location; that provider is available in the list unless you select a different provider and then save the change.

   • Note - The text of the note. Edit the note text, and/or insert notes from templates.

4. If the note is complete, and if you are the selected provider or have permission from the provider, you can sign the note. To sign the note, click (or tap) the Sign as [provider name] link, and then enter the selected provider's or, if you are the provider, your password in the Password box that appears.

   Note: The Sign as [provider name] link is available only if a digital signature for the selected provider has been set up.

5. Click (or tap) Save.

6. Whether or not a secondary provider is associated with the clinical note, if an additional provider needs to sign the note, re-open the clinical note.

   

   If the incorrect provider or [None] is selected in the Additional Provider list, select the correct provider to associate with the clinical note. If you are the selected provider or have permission from the provider, you can sign the note. To sign the note, select the Sign as [provider name] checkbox, and then enter the selected provider's or, if you are the provider, your password in the Password box that appears. Then, click (or tap) Save.