From the practice dashboard, you can create clinical notes that were not entered that should have been. A clinical note is considered to have not been entered if a clinical note with you as a provider has not been entered on the service date of a completed procedure with you as the provider and if that procedure has been set up to require a clinical note.
Common reasons why a clinical note is counted as Not Entered:
The provider who is assigned to the procedure has not signed the clinical note as the main provider (the first signature).
The date of the clinical note does not match the date of the procedure.
Procedures are posted after the clinical note is signed. Another clinical note must be created and signed.
To enter clinical notes
On the Home menu, under Location, click (or tap) Overview.
The location's Overview page (dashboard) opens.
Click (or tap) the Not Entered column of the Clinical Note Tasks box. This column displays how many clinical notes were not entered today and during the previous 30 days that should have been. A clinical note is considered to have not been entered if a clinical note with you as a provider has not been entered on the service date of a completed procedure with you as the provider and if that procedure has been set up to require a clinical note.
The Clinical Note Tasks page opens with the Not Entered tab selected.
By default, the Date Range is set to display patients without notes for the last 30 days, but you can change the date range to filter the list as needed. Select Today, Yesterday, Last 7 Days, Last 30 Days, Last 180 Days, This Month (since the first day of the current month), or Custom Range (specify the Start Date and End Date, and then click, or tap, Done).
Select a patient.
On the right, the options for entering a corresponding clinical note appear. Under Note Not Entered for [Patient Name], the procedures posted for the selected patient on the corresponding date appear for your reference.
Click (or tap) Add Note.
The Add Clinical Note dialog box appears.
Set up the following options:
Th - To assign tooth numbers to the note, click (or tap) the Assign teeth link, select the applicable teeth, and then click (or tap) X.
Provider - The provider to associate with this note. Only providers who have access to the current location are available.
Note: If the patient has a preferred provider (primary provider), when you create a clinical note, the preferred provider is selected automatically in the Provider list. If you select a different provider, the preferred provider is selected automatically in the Additional Provider list.
Recommendation: As the patient's provider of record, the primary provider should enter a clinical note for the work performed even if he or she has already signed a clinical note as the Additional Provider on that day.
Date - The date of the note. Leave the current date selected, or click (or tap) the box to select a different date.
Additional Provider - A secondary provider (such as a hygienist) to associate with this note. To associate an additional provider with the note, select that provider; otherwise, leave [None] selected. Only providers who have access to the current location are available.
Note - The text of the note. Enter the note text, and/or insert notes from templates.
If the note is complete, and if you are the selected provider or have permission from the provider, you can sign the note. To sign the note, click (or tap) the Sign as [provider name] link, and then enter the selected provider's or, if you are the provider, your password in the Password box that appears. However, if the note needs to be finished later, or if the provider has to review the note, the note can be signed later.
Note: The Sign as [provider name] link is available only if a digital signature for the selected provider has been set up.
Click (or tap) Save.
Repeat steps 3-8 as needed to enter and sign other clinical notes.