There are many different places for notes in Open Dental. This page describes which notes should be used for which purposes and protocols your office should use in organizing your notes.

Clinical Notes

Chart Notes	Procedure Notes	Miscellaneous Notes
Progress Notes	Clinical Notes	Exam Sheets
Tooth Chart Notes	Procedure Notes	Medical/Service Notes
Perio Chart Notes	Default Procedure Notes	Chart Letters
Ortho Chart Notes	Group Notes	Treatment Plan Notes

Progress Notes

The Chart Module's Progress Notes grid displays Clinical Notes, Procedure Notes, and Group Notes at a glance. Chart Views can be used to easily filter this information, and right-clicking the grid provides an option to print the displayed Progress Notes.

Tooth Chart Notes

The Graphical Tooth Chart allows custom text to be entered and moved to the desired location on the tooth chart. Freehand drawing is also available using a mouse or touch screen.

Perio Chart Notes

Exam Notes can be used in the Perio Chart window to enter relevant information for the selected exam.

Ortho Chart Notes

The Ortho Chart can be customized in Preferences and includes an option to enter notes.

Clinical Notes

Pre-configured procedure codes can be used, such as a clinical note or a procedure note (i.e., Zclin and N4117). These procedures can be charted and procedure notes can be entered on them. These procedures are typically set up as Procedure Buttons for faster entry.

Procedure Notes

Procedure Notes are entered in the Procedure Info window. Use Procedure Notes in the Chart Module to document anything that normally goes into your chart notes, such as materials used, procedures followed, treatment performed, anesthetic, informed consent, etc. Once a Procedure Note is saved, if changes are made and saved, previous versions of the note are archived and can be viewed from the Chart Module by clicking the Show tab and checking Audit.

Additionally, Procedure Notes can be set up to use two quotation marks (i.e., "") as a reminder to complete the note. If the note is not completed, a red Incompleted Note warning appears above the note and the procedure will be displayed in the Incomplete Procedure Notes Report.

Default Procedure Notes

You can optionally set up default Procedure Notes that copy automatically into a procedure every time a procedure is treatment planned or set complete; that way only very minor changes need to be made. Default Procedure Notes can be set for a specific procedure code in the Edit Procedure Code window.

Group Notes

Procedure Group Note is a single note that can be attached to multiple procedures for the same patient or can be a standalone note. Group Notes are helpful to avoid having to enter duplicate notes on multiple procedures.

Exam Sheets

Exam Sheets can be used to track findings during an exam as well as any notes for that day. Create custom Exam Sheets by editing the Exam Sheet Layout. Exam Sheets are available in the Chart Module, Progress Notes area and can also be used with Automation.

Medical/Service Notes

In the Chart Module, the Medical window has a place to enter Med Urgent, Medical Summary, Medical History and Service Notes. Med Urgent, Medical Summary, and Service Notes are displayed in the Patient Info section of the Chart Module. Medical History notes are only viewable from the Medical window. Med Urgent notes are displayed in bold red font and can be set to show on appointments in Appointment Views.

Chart Letters

Chart Letters are used for longer notes that require additional security, typically oral surgery. These notes are written in a Word document which is easily accessible from the Chart Module and warns a user if the notes have been edited externally.

Treatment Plan Notes

Customize the note that shows on printed Treatment Plans.

Appointment Notes

• Appointment Notes and Fields
• Patient Notes
• General Notes

Appointment Notes and Fields

The Edit Appointment window contains an Appointment Note field and Appointment Field Defs (i.e., customizable appointment fields) which can be displayed on the appointment from the Appointments Module. The Appointment Note field allows additional appointment information to be entered. Appointment Field Defs can also be used to add appointment-specific notes and are customized in the Appointment Field Defs window.

Patient Notes

Sometimes you want notes to show in the Appointments Module schedule that are not part of appointments or procedures. Patient Notes can act as reminders to call a patient at a specific time, to run recurring credit card payments, to follow up on phone calls, or to call patients who request to be called if a patient cancels. Simply create an appointment with a note and no procedures.

Set the Patient Note color in Definitions: Appointment Colors. This overrides provider and appointment type color and will change when the note is set complete.

General Notes

General notes that are not attached to a patient can also show in the Appointments Module. For example, add notes about office schedule changes, staff out, holidays, meetings, notes to staff, etc.

1. Create a new patient called Miscellaneous, Notes or something similar. Remember that the displayed format will be Last Name, First Name.
2. Select the dummy patient and schedule an appointment or create a Patient Note. On the Edit Appointment window, enter the note in the Appointment Note field.

If adding the general note as an appointment, customize the color by creating an alternate provider for the note (e.g., NOTE). Select the NOTE provider on the Edit Appointment window to use the color.

Account Notes

• Fam Urgent Fin Note
• Family Financial Notes

Fam Urgent Fin Note

Family Urgent Fin Note applies to the entire family. Important financial notes can be entered as a Family Urgent Fin Note at the top of the Account Module. This note displays in red font and applies to all family members. Any changes affect all family members. The note displays when hovering over an appointment and on the Patient Appointments window.

Family Financial Notes

Family Financial Notes are non-urgent notes regarding the family account that do not need to be tracked in the Audit Trail. Not regularly used.

Demographic

• Address and Phone Notes
• Odontogram Notes

Address and Phone Notes

Address and Phone Notes can be entered in the Edit Patient Information window. Make notes about when to call a patient, which number the patient prefers, extra phone numbers, extensions, bad phone numbers, bad addresses, alternate addresses, etc. Text entered into this field is shown in bold red in the Patient Information area of the Family Module. These notes also show in the Unscheduled list, Recall list, and appointment.

Odontogram Notes

Odontogram Notes can be entered in the white text box below the Graphical Tooth Chart in the Chart Module. This field can be used for any notes that are not pertinent to the patient's treatment. The history of these notes is not saved or tracked.

General Purpose

• Commlogs
• Tasks
• Popups

Commlogs

Commlogs are for non-clinical patient communication. These are useful for documenting conversations had with the patient and other communications like email, patient and referral letters, phone calls, insurance calls, etc.

Tasks

Tasks are useful for interoffice communication and reminders. Tasks can be sent to specific user's inboxes or to group inboxes (e.g., Front Desk, Hygienists). Task Reminders can be set up to show on the specified date and time.

Popups

Popups are messages that automatically display when a patient is selected.

Note Templates

• Auto Notes
• Quick Paste Notes

Auto Notes

Auto Notes are templates used to insert frequently entered, large notes (e.g., for hygiene, root canals, materials, anesthetic, post op instructions). They can contain prompts and pre-filled text. Auto Notes can be edited in Auto Note Setup.

Quick Paste Notes

Quick Paste Notes are used as a shortcut to easily insert frequently used notes or templates. Abbreviations can be assigned to a Quick Paste Note so when the abbreviation is typed (e.g., ?dlb), the full note is added. Alternatively, in many text boxes, you can right-click to open a list of Quick Paste Notes and select a note to insert. Quick Paste Notes can be created and customized in Quick Paste Notes Setup.

Additional Resources

See our video: Clinical Charting II: Clinical Notes Webinar.