How to Add Event-Based Clinical Notes

You can insert clinical notes into a current or previous date (day-based), or provide additional details to clinical events, using the Insert Note function on a patient's Hard Tissue Chart (US) or Dental Chart (UK), Clinical Chart (EMR), Soft Tissue Chart, Perio Chart, Orthodontic Clinical Summary, and Treatment Plan screens.

Note: A day-based clinical note does not have to coincide with an appointment. For example, you might insert one when a lab result is returned or a patient calls to report a clinical issue.

To insert a clinical note:

1. From the Patient tab, click Clinical and select a clinical view.
2. From the Clinical Chart (EMR) screen, locate the day for which the new note is required and click Add to Chart > Clinical Note.
   
   OR
   From the clinical events list on the left of the Hard Tissue Chart/Dental Chart, hover your cursor over the list of notes/events on the left and select Insert Note.
   
   The Clinical Note For [Patient] window is displayed.
3. Start typing to enter new free-form clinical note text, or select a clinical notes template to add pre-defined text into the note.
   Note: Only active templates are available for selection. When the logged-in user has templates that are associated with them, these templates are listed by default. The Associated to selection must be changed to All Users to display all available active templates for the practice. The selection is set to All Users by default when the logged-in user does not have any associated Clinical Notes templates.
4. If you select a template, click Insert Text, and then edit the note as needed.
   Note: If applicable, click on the blue questions in the template to select or type an answer.
   
5. Click Save to save the note or click Save & Sign to save the note and add a provider signature. If you select Save & Sign, the Clinical Note Approval window is displayed.
   
6. Select a Provider and enter the PIN. 
   
   Note: 
   -- Only providers that have assigned PINs are available for selection in the drop-down list. 
   -- The default provider for the patient is automatically selected if the logged in user does not have a PIN assigned, but you can change the selection. 
   -- See How to Create a Provider PIN for Signing Clinical Notes for information on creating a provider PIN.
7. Click Sign.
   Note: If a clinical note is edited, this prompts the need for a new signature and the Sign button becomes active. 

Clinical Events

Clinical events and related notes are displayed on the left side of clinical screens in the Actions panel. Hover over an existing clinical event (such as an observed condition or planned / completed procedure) and click Insert Note.

You can scroll within the clinical note’s container or click Show More to view a popover with a larger view of the full clinical note text.

Note: You can also hover over the note/event to access the Edit (pencil) and Remove (x) icons. If you remove a note, a temporary message is displayed indicating the note has been removed and providing an Undo option if it was removed in error. If a note has been changed, you can click the Note History icon (clock) to view the history.