Learn how to make changes to clinical notes and when it’s appropriate to do so.
Using the Dentrix clinical notes feature, you can add free-form notes about the patient exam to your patient records. You can also set up clinical note templates for routine notes. Your clinical notes are an important part of the patient record and should not be deleted or altered without a feature to track the changes you make.
After your clinical notes have been locked, the Dentrix addendum feature lets you easily track any changes you make to your clinical notes and when you make them. If you sign the note or run the month end update or month end wizard for the month in which the clinical notes were entered, the clinical note will be locked into History.
If you need to alter the clinical note after it has been locked into history, the only way to do this is with an addendum. The addendum is attached directly to the original note with the date the addendum was added. After you have saved the addendum, it is also locked into History and cannot be altered or deleted. If you ever need to print your patient’s clinical notes, you will see the date of entry of the original note and the date of the addendum.
To add an addendum to a clinical note, with a patient selected in the Patient Chart, from the View menu, point to Panels, and then click Clinical Notes. Select the clinical note that you want to add an addendum to. In the Clinical Notes toolbar, click New Addendum.
In the New Addendum dialog box, type the note that you want to append. Select the provider you want to attach to the addendum from the list. Click OK, and then click Yes to append the note. There may be times when you will need to specify a different date on a clinical note, other than the current date. For example, if the doctor comes into the office on the weekend to see a patient and does not write up the clinical note on that day, the doctor will need to specify the date the actual work was performed.
If you are adding a clinical note into a month that has already been closed out, your note will automatically be secured into History. Also, if you date a note anything other than the date on which the clinical note was created, it will show both the date the note was actually created as well as the date to which it was changed (the date the work was actually performed).
To change the date on a clinical note, with a patient selected in the Patient Chart, from the View menu, point to Panels, and then click Clinical Notes. Select the clinical note whose date you want to change, and then click the Change Date for Selected Clinical Note toolbar button. In the Change Date and Time box, specify a new date and time for the clinical note, and then click OK.
Knowing how your clinical note documentation will present when printed is important if and when you need to show your clinical documentation. The Dentrix software does a great job showing the dates and times of your clinical notes so you can feel confident in the integrity of your clinical documentation.
To learn more about clinical notes, see the “The Clinical Notes panel” topic in the Dentrix Help. Read “Stay on Top of Your Clinical Notes” and “Clinical Notes Made Easy” to get ideas about improving your efficiency with clinical note templates.
Visit https://www.dentrix.com/solutions/clinical-efficiency for ideas about how to improve clinical efficiency with Dentrix.
By Dayna Johnson, Certified Dentrix Trainer
Dayna loves her work. She has over 25 years of experience in the dental industry, and she’s passionate about building efficient, consistent, and secure practice management systems. Dayna knows that your entire day revolves around your practice management software—the better you learn to use it, the more productive and stress-free your office will be. In 2016, Dayna founded Novonee ™, The Premier Dentrix Community, to help cultivate Dentrix super-users all over the country. Learn more from Dayna at www.novonee.com and contact Dayna at email@example.com.