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Procedure Notes 

Procedure notes are daily treatment notes that are stored with the procedure. They can include anything normally goes into your chart notes, such as materials used, procedures followed, treatment performed, anesthetic, informed consent, etc. Procedure notes support Electronic Signatures.

Hints
Default Notes: To simplify data entry of procedure notes, set up default notes for Procedure Codes that automatically copy into a procedure when it is added to a patient's chart. Default notes can be set up for treatment planned and/or completed procedures.

  • Completed Note: A note that automatically copies to the Procedure Info window, Notes field when the procedure is Set Complete.
  • TP'd Note: The note that automatically copies to the Procedure Info window, Notes field when the procedure has a status of treatment planned.

Incomplete Notes: Use two quotes "" in a note to remind staff to enter specific information in a note (Example: Due Date ""). If the information is not completed within the procedure, a red 'Incomplete Note' warning will appear above the note. To view a list of completed procedures with incomplete notes, see Incomplete Procedure Notes Report. Other examples: composite shade, crown shade, denture shade, due date, blood pressure, nitrous levels, etc.

Auto Notes: Insert Auto Note in procedure notes to prompt staff to enter information. In Chart Module Preferences, check 'Procedures Prompt for Auto Note'. Then, opening the Procedure Info window will trigger any unanswered auto note prompts.

Procedure Group Notes: Create one Procedure Group Note for multiple procedures instead of attaching notes to individual procedures.

For other note options, see Notes Overview.

Security
All procedure notes are automatically and permanently locked, and nobody can edit, regardless of their Permission. For convenience, we do give users the illusion of being able to edit and delete notes. Every change is recorded, and an archived note history can be viewed in the Chart module under Show tab, Audit.

Permission-based Locking: There are several user security Permissions that affect access to procedure notes.

  • Edit Completed Procedure (full)
  • Edit Completed Procedure (limited)
  • TP Procedure Delete
  • Procedure Note 

Procedure Locking: A few offices insist on locking procedures and only allowing notes to be appended. This option is not used by most offices. See Procedure Locking.

Examples
Below are some examples that show the difference between default procedure note templates and auto notes.

Strategy 1: Fill in the blank default note. This is an excellent strategy.
Comprehensive Exam
Medications:
Allergies:
Medical Conditions:
PSR:
Overall PSR:
Soft Tissue Screening:
Dental Exam: Treatment plan printed.
Pt Concerns:
PARQ: ""

Strategy 2: Prefilled default note. Slightly more efficient, more complete, but risk of inaccurate notes.
Comprehensive Exam
Medications: none
Allergies: none
Medical Conditions: none
PSR:222222
Overall PSR:2
Soft Tissue Screening: WNL
Dental Exam: No caries. Treatment plan printed.
Pt Concerns: None
PARQ.

Strategy 3: Auto note 
Comprehensive Exam
Medications: (pick from list)
Allergies: (pick from list)
Medical Conditions: (pick from list)
PSR:222222
Overall PSR:2
Soft Tissue Screening: (pick from list)
Dental Exam: No caries. Treatment plan printed.
Pt Concerns: None
PARQ.

 

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