Oral Surgery Clinical Chart (EMR) – Carestream Dental

Related Training
Using the Clinical Chart EMR Recorded Class

Note: This version of the Clinical Chart (EMR) is available for practices that have Oral Surgery features enabled.

For more information, see the Sensei Cloud Oral Surgery Feature Overview.

The Clinical Chart (EMR) interface for Oral Surgery displays a chronological, text-based view of clinical events that have occurred via the Hard Tissue, Soft Tissue, and Perio Charts, as well as the other corresponding clinical screens.

From the Patient tab, select Clinical > Clinical Chart (EMR). Use this screen to manage current appointments, document walk-in appointments, define chief concerns, create a lab case, collect data with a selected questionnaire, record vital signs, document implants, and insert notes into events in the list. You can also add information to previous appointments, as well as scheduled appointments that have not yet occurred.

See the following sections and articles for more information:

Tracking Widgets
Anesthesia Records
Define Chief Concern
Manage Appointment
Clinical Note Templates
Implants
Vital Signs

Tracking Widgets

You can also use the panels on the top of the chart to access and update:

Medical Alerts
Medications
Allergies
Patient Information:
-- Referral Source: An active referral source that is assigned to the patient in their record is displayed, if applicable. Click the referral source name to view the Referral Details as well as a hyperlink to the referral source entry. See How to Manage Referral Sources and How to Add a Referral Source to a Patient Record for more information.
-- Additional Outside Doctors: COMING SOON!
-- X-Ray: The dates of the patient's last bitewing and Pano/FMX X-Rays. Only one date is displayed on the panel, but you can click on the date to view both the Last BW and Last Pano/FMX dates. This is displayed as N/A if no X-Rays have been taken for the patient.
-- Preferred Pharmacy: The patient's preferred pharmacy which can be added from the patient record, patient home page, Patient Snapshot, or right here from this widget in the clinical chart. See How to Store and View the Preferred Pharmacy for Patients for more information.

Anesthesia Record

Select Add to Chart > Anesthesia Record. Fill out the General Information, Pre-Op Evaluation, Surgery Info, Surgery Vitals, and Post-Op Evaluation tabs.

Define Chief Concern

Select Add to Chart > Chief Concern. Select the patient's primary concern and add relevant details.

Manage Appointment

For current appointments, click Manage Appointment to update procedures and notes for the appointment.

Note: You can use the copy icon to add another instance of a procedure to the list.

Note: When you enter a procedure, you are prompted to enter a diagnosis code:

From the Manage Today's Appointment window, click Save Changes to continue with the appointment, or Complete Appointment after entering any final notes, and to mark the appointment complete.

Clinical Notes Templates

Select Add to Chart > Clinical Note to add a customized clinical note to the Clinical Chart (EMR). A starter set of oral-surgery specific templates is included with the Oral Surgery package. Use them to create your own customized correspondence, and click the green star to mark your favorites.
Note: Base templates cannot be edited, but you can customize and save them under a new name.

To access the list of templates, select Administration > Templates > Clinical Notes Templates. From that screen, you can view the list of base/stock templates, copy a template to customize and save it under a unique name, edit customized templates, and change the status of a stock template to Inactive to hide it from the list.

Implants

Select Add to Chart > Implants to add implants to a patient's chart. For more information, see How to Track Implants in the Clinical Chart (EMR).

Prescriptions

Select Add to Chart > Prescription. For more information, see How to Issue a Patient Prescription.

Treatment Plans

Select Add to Chart > Treatment Plan. For more information, see How to Create or Edit a Patient Treatment Plan.

Vital Signs

Select Add to Chart > Vital Signs to record the patient's vital signs. For more information, see: