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. 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” 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.
For more tips designed for Dentrix Office Managers, subscribe to the Dentrix Office Manager blog at thedentrixofficemanager.blogspot.com.
By Dayna Johnson, Certified Dentrix Trainer
Dayna Johnson, founder and principal consultant of Rae Dental Management, helps dental offices improve patient care, increase collections, and reduce staff headaches by implementing efficient management systems. With 23 years of experience in the business and technical side of dental offices, Dayna’s passion for efficient systems is grounded in both personal understanding and professional expertise. Dayna can be reached at [email protected] or visit her website at www.raedentalmanagement.com.
Originally published in Dentrix Magazine, Spring 2018