View Treatment Notes screen. View Video, 2 min. 51 sec.
Writing detailed treatment progress notes is not only important clinically, but legally. If you ever find yourself as a defendant in a court of law, you must have detailed treatment notes that chronicle all aspects of your care for that patient. What was the reason for the patient’s visit to your office? Did you clearly state your diagnosis? What treatment did you perform? Were health history concerns noted? What type of anesthetic carpule did you use and how many? Did it contain epinephrine, and, if so, what concentration? What other medications were used and at what dosage? What type of retraction cord did you use? Did you note that you gave the patient pre-op or post-op instructions? What plan did you have for the patient’s next visit? Etcetera, etcetera. Most busy dental practices simply don’t have time to hand write detailed treatment notes for every patient. With so many patients coming through the door every day and so much other work to do, office personnel usually do not have time to write treatment notes with this level of detail.
The two main purposes of the Treatment Note module is:
- To allow you to store your treatment notes in the computer for easy access instead of a paper chart.
- To allow the automated addition of details to your notes that they otherwise would not contain.
Entering Basic Treatment Notes
Treatment notes are accessed through the patient’s Posting screen. From the Main Menu click Posting and search for the patient in question. On the Posting screen click the Treatment Notes button. The Treatment Notes screen will appear. You will notice the screen is split into a large upper pane and a smaller lower pane. The upper pane is called the Editing Window and is where you edit and view the current treatment note. The lower pain is called the Treatment Notes List Box and displays a scrollable list of all the entered notes for this particular patient. In the Treatment Note List Box, notes are sorted in the order they were entered (most recent first), and not necessarily by the date the treatment note was given. Therefore, backdated notes will still be listed in the order they were entered. To create a treatment note click the Create Tx Note button, type your note into the Editing Window and click the Save button. You will see the treatment note added to the Treatment Note List Box at the bottom of the screen.
The Editing Window
The Editing Window functions like a mini word processor. You simply type your treatment note into this window. Like a word processor the text will automatically scroll and like a word processor you can hit the enter key to force a new line. The Editing Window has many of the same controls used in Microsoft Word and even uses the same icons. These controls include: Undo Typing, Redo Typing, Cut, Copy, Paste, Search, Find and Replace. The Date of Tx Note field designates the date of the note. When creating a note the current date will automatically display in this field. You can change it to any date if you wish. The Provider field will automatically display the account’s assigned doctor. If the account does not have an assigned doctor then the doctor you have designated as the default doctor will display automatically.
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