The documentation of procedure visit details is a critical component to every patient encounter. Many dentists adopt the SOAP format to ensure complete documentation. SOAP is an acronym for Subjective, Objective, Assessment, Plan and is a format which can be universally applied to every clinical note.
- Subjective: the chief complaint presented by the patient
- Objective: clinical findings and observations
- Assessment: diagnosis of your patient’s chief complaint and clinical findings
- Plan: treatment plan or recommendations for care
The format of documentation is a process nearly every dental office has dialed in before they reach out to a trainer for guidance. After all, this is a practice that is in place and documentation is made in the paper chart of each patient. So what happens when you are ready to take your clinical note documentation to the next level?
Arguably one of the more arduous tasks you may encounter with going chartless will be the process to convert your clinical notes from paper to computer. Over the past few weeks, I have been working closely with an office who presented a challenge when taking their clinical note documentation to a digital format. When they first contacted me, they were a few weeks into the project already and had developed a plan to enter all clinical notes into Easy Dental through the Clinical Notes screen. The staff entered clinical notes at the end of every visit. They were pleased with the clinical note templates that were available in Easy Dental, they had even created some custom notes they could use. The concern they wanted to address was a desire for more from their clinical note entry process. They wanted a more advanced level of clinical note templates and faster entry.
Just the Basics
Before we jump into the solution for clinical note automation, let’s first discuss some Easy Dental Clinical Note basics:
- Access to Clinical Notes is found within the Chart module.
- Clinical notes are stored by date. To switch between clinical notes, use the Previous and Next buttons.
- Clinical Notes can be generated by free-type or templates. To free-type a clinical note, simply click in the white note field to place your cursor and type your note as you would type into any word processing program.
- Pre-formatted templates are provided for quick entry of exam details for Soft Tissue, Functional, Periodontium and Oral Hygiene. Orthodontic is a divider label , indicating a change from any general notes to orthodontia notes entered on the same date.
- Custom Notes are short sentences that can be custom created in Practice Definitions. Example Custom Notes are displayed in the image below. Access to Custom Notes / Practice Definitions is found in the Report screen within Practice Setup.
Clinical Note Automation – Example
Easy Dental provides a solution for automating your standard clinical notes when procedures are set complete. Let’s say your patient presented for a prophy today. When the prophy service code (D1110) is set complete, a clinical note is automatically generated for your patient (sample shown in image below).
Simply posting the procedure code D1110 complete generated this clinical note. This greatly simplifies the hygienist’s task of entering the clinical note. All they need to do at this point is check and edit the note as needed.
Clinical Note Automation – Setup
We have defined that automatic clinical notes are driven by the action of setting complete procedure codes, so it is logical that the setup of automatic notes will be completed in Procedure Code Setup.
- Access Procedure Code Setup in the Report screen in the Practice Setup menu.
- Locate the Procedure Code Category (1) and Procedure Code (2) you wish to create an automatic note for, then select Edit (3).
- From the Procedure Code Editor, click Edit Note in the lower left.
- Type your clinical note into the Procedure Code Progress Note field. Choose Copy to Clinical Note and click OK.
- You will now be back in the Procedure Code Editor. Click Save and Close to close out of the procedure code setup windows. Test your new automated clinical note by posting a D1110/Prophy to a test patient. Modify the clinical note with free-typing into the clinical note field.
Clinical note automation is a great tool for simplifying the task of clinical note entry. Saving time and energy in the fast-paced dental office is a win-win solution every day of the week. Please comment and share your ideas with us below.
For additional information, see the following topics in Easy Dental Help: