Clinical Notes Made Easy

The Clinical Note Templates feature in Dentrix helps you improve clinical note efficiency, accuracy, and consistency.

Updated 6/30/20

You’ve just finished confirming tomorrow’s appointments, so you begin pulling the patient charts to have them ready for tomorrow. That’s when the hunt begins. You discover that the file for Tim Jones is missing. First you check to see if it was misfiled–honestly, how many ways can you spell “Tim Jones?” You look through your “in” boxes and the “to-be-filed” box. Not there. After drumming your fingers on your desk, you finally go to that one place where all missing charts go to hide: the doctor’s office. There it is, under a pile of Dental and Golf magazines, right where the doctor left it after adding his clinical notes.

How can you avoid this all-too-frequent scenario in the future? The answer is to update patient chart and clinical note information using the computer. Dentrix makes it easy. Using Clinical Notes Templates, all the doctors and hygienists can easily record specific details in their clinical notes while maintaining the important consistency, accuracy, and legibility that’s often missing from handwritten notes. Clinical Notes Templates can also help prevent spelling errors. (Have you ever noticed the many different ways people spell hygiene?) Not to mention the time you’ll save! You can accurately record several paragraphs of patient notes in just a few minutes. With Clinical Notes Templates, you can also read all your clinical notes from any computer, and you can sign and lock the notes into history.

Clinical Notes Templates are included with your Dentrix Patient Chart. All you have to do is design your templates. Let’s begin by looking at some typical new patient exam notes, which might look something like this:

Patient was seen for a New Patient Exam.

Xrays: FMX and BWX

CC: gums bleeding when brushing.

OH: Fair

Calculus: Moderate

Stain: Light

OCS: Neg

For consistency, the questions for a new patient exam should always remain the same. It’s the answers that change from patient to patient. Here’s the 90/10 rule I use: the 90 percent of text I write for every new patient exam–text that never changes–is work the computer can do; the information I change for each patient is usually only about 10 percent.

In the example above, the constants are:

Patient was seen for a New Patient Exam.

Xrays:

CC:

OH:

Calculus:

Stain:

OCS:

Because these clinical notes are for a new patient exam, this first line will never change. The other lines identify other clinical note details that will be recorded during each new patient exam.

Using Clinical Notes templates also eliminates the need for arcane abbreviations. For example, does CC in the example above stand for Carbon Copy, Continuing Care, or Chief Complaint? The answer is Chief Complaint. In the past when clinical notes were all handwritten, the healthcare system allowed for abbreviations so that doctors or hygienists didn’t have to waste time writing out every word. Now that software can automatically enter the complete word–making it easier for people to understand what you mean–abbreviations are not necessary.

Exercise: Designing a Template

For practice, let’s create a template in Dentrix. Follow the steps below to design a New Patient Exam template that you can use for clinical notes during every new patient exam.

With a patient selected in Patient Chart, click the Clinical Notes tab at the bottom of the window. Next, click the Template Setup icon on the right of the panel.

In the Template Setup dialog box, click New.

This opens the New Clinical Note Template dialog box where you will create your template.

In the Category field, select the Clinical Exams category. In the Template Name field, type New Patient Exam. In the Clinical Note Text area, type Patient was seen for a new patient exam, then press ENTER to begin a new line. Type the first question word, Radiographs, followed by a colon and a space.

Adding a Prompt to the Template

Now we’ll add the first prompt. Click Select/Setup to display the Clinical Note Prompts dialog box with predefined prompts that you can use.

We want to add a prompt that reads “Radiographs,” but this prompt is not available in the list. If a prompt you need is not listed, you can create your own. Click New to display the New Prompt dialog box, and type the name of your prompt, Radiographs, in the Prompt Name field.

In the Prompt Text field, type What radiographs were taken?. The Response Type gives you different options for your answers. In this case since multiple answers are possible, choose Checkbox Responses. Now enter all the possible answers that could come up for this question, one answer per line. When finished, click OK, then OK again. Now click Insert Prompt In Text. Add the other prompt questions and answers. When finished, click OK and then Close.

Using the Template

Your template is now ready to use, and you can find it under the Clinical Exam category in the clinical notes list.

Click the New Clinical Note icon, then double-click New Patient Exam, and the first prompt appears.

Select the answers to the questions you have defined. When you finish responding to the prompts, your completed clinical note will appear in the Patient Chart with the custom answers that you have chosen.

Now that your template is set up, adding specific information for a new patient exam is a snap! All the other types of clinical notes you record can be set up with a similar template just as easily to improve efficiency, accuracy, and consistency.


Learn More

Read “Stay on Top of Your Clinical Notes” for tips about managing the clinical note process.

To learn more about using the Clinical Notes Templates, see Creating clinical note templates in the Dentrix Help.

Visit https://www.dentrix.com/solutions/clinical-efficiency for ideas about how to improve clinical efficiency with Dentrix.


By Melinda Dyches, Dentrix field training manager

Originally published in Dentrix Magazine, Fall/Winter 2010