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, 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:
- From the Patient tab, click Clinical and select a clinical view.
- From the Clinical Chart (EMR) screen, locate the day for which the new note is required and click Add to Chart > Clinical Note.
From the clinical events list on the left of the Hard Tissue Chart, hover your cursor over the list of notes/events on the left and select Insert Note.
The Note For [Patient] window is displayed.
- 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.
- If you select a template, click Insert Text, and then edit the note as needed.
- Click Save.
|Tip:||You can leave the note entry window open while you gather details from the patient’s clinical screens. Click and drag to move it around the screen. The note remains open while you perform other tasks on the Patient's UI, as long as this patient is the active tab. If you navigate to another patient or another part of the software, you are prompted to save the note. Click Save to close the window.|
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.