You can add clinical notes by typing them from scratch or by using a template. Using a clinical note template as a guide, you can quickly and accurately document a patient's visit with minimal typing or editing.
Notes:
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.
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.
Adding clinical notes requires the "Clinical Notes, Modify" security right.
To add a clinical note
Do one of the following:
To add a clinical note, do the following:
Click
the New Clinical Note button 
.
The Change Date and Time dialog box appears.
By default, the current system date and time is entered, but you can change it. To specify a different date and/or time, do any of the following:
To change the month, select the month portion of the date and then enter a month as a 1-digit or 2-digit number.
To change the day, select the month portion of the date and then enter a day as a 1-digit or 2-digit number.
To change the year, select the year portion of the date and then enter a year as a 2-digit or 4-digit number.
To change the hour, select the hour portion of the time, and then enter an hour as a 1-digit or 2-digit number.
To change the minute, select the minute portion of the time, and then enter a minute as a 1-digit or 2-digit number.
To change the second, select the second portion of the time, and then enter a second as a 1-digit or 2-digit number.
To change the time of day (AM or PM), select the AM/PM portion of the time, and then type AM or PM.
Click OK.
To add a page to an existing clinical note, do the following:
Expand the appropriate date in the left pane, and then select a note.
Click
the New Clinical Note Page button
.
The Change Time dialog box appears.
By default the current time is entered, but you can change it. To specify a different time, do any of the following:
To change the hour, select the hour portion of the time, and then enter an hour as a 1-digit or 2-digit number.
To change the minute, select the minute portion of the time, and then enter a minute as a 1-digit or 2-digit number.
To change the second, select the second portion of the time, and then enter a second as a 1-digit or 2-digit number.
To change the time of day (AM or PM), select the AM/PM portion of the time, and then type AM or PM.
Click OK.
Notes:
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 that 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 may appear. Edit, enter, or select an encounter number, and 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, [123456]) after the note number.
The new page (Pg[number]) is listed under the selected note (Note#[number]).
3. Do any of the following as needed.
Manually enter text - In the note box (in the center pane), enter text regarding an exam or treatment given.
Insert text using a template - Do the following:
In the template list (in the right pane), 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.
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 box (in the middle), and you can skip step c.
Respond to the prompts that are associated with the template, if applicable.
The template text is automatically entered into the note box.
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.
Edit the resulting note, or add information to it as needed.
Notes:
To
check the spelling of the note text, click the Check
Spelling button 
(this button is available only if a certain preference
setting has been enabled).
A clinical note page can contain up to 7,700 characters. The maximum length of a clinical note page is 8,000 characters, but 300 of those characters are reserved for the signature line that is added when a clinical note is signed.
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 is a Change Encounter for Selected Note button on the toolbar. To edit the encounter number, click the button. The Edit Encounter Number dialog box appears. Edit, enter, or select an encounter number, and then click OK.
If
you need to assign a different clinic than the clinic that is currently
selected for the clinical note, click the Change
Clinic for Selected Note button 
.
The Select Clinic dialog box appears.
Select the correct clinic, and then click OK.
Note: If your user account has been granted the "View All Patients" security right for the Central clinic, the ID and name of all clinics appear in the list; otherwise, the ID and name of each clinic for which your user account has been granted the "My Clinics, View" security right (in the "Practice/Clinic Setup" category) appear in the list; however, if your user account has not been granted that right to any clinic, only the ID and name of the clinic that you are currently logged in to appear in the list.
Click
the Save Clinical Note button
to save the note.
Notes:
The note is saved automatically if you go somewhere else in Dentrix Enterprise or if you close Chart (if you had opened Clinical Notes from Chart).
You can add additional information to an existing clinical note at a later date and time unless the note is locked (when a clinical note becomes locked is determined by a certain global setting). If the note is locked, you cannot change it, but you can add an addendum.