There are many different places and tools for notes in Open Dental.

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

Procedure and Group Notes

In the Procedure Edit window, at the right, is the Procedure Note area.

Notes can be added to a single procedure from the Procedure Info window. Notes can be added when a procedure is still treatment planned or after it has been set complete. These notes can be electronically signed or stamped.

Additionally, the Group Notes feature can be used to add a single note for multiple procedures.

In the Chart Module, highlight multiple procedures for a patient. Right-click and select Group Note.

Both procedure notes and group notes can be viewed from the Progress Notes area of the Chart Module.

Chart Letters

Can be used for longer notes, 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.

Note Templates

The Auto Notes and Quick Paste Notes features can be used to easily input commonly-used note information.

Auto Notes

Place cursor in a Procedure Note box. Above the box, click Auto Note.

Auto Notes are most useful for longer form notes that require input (e.g., SOAP notes).

These notes both input text and prompt for additional information. Prompts can be set up to allow you to choose from a preset list of options or enter free-form text. Auto Note templates and prompts are customizable.

Quick Paste Notes

In the Main Menu, click Setup, Quick Paste Notes.

Quick paste notes are useful to easily insert text. Abbreviations can be assigned to a Quick Paste Note so that when you type the abbreviation (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.

Chart Module Notes

There are various areas in the Chart Module to enter notes that may not be related to specific treatment.

Tooth Notes

Notes can be added directly to the Graphical Tooth Chart using the tools in the Draw tab of the chart. Procedure codes can also be set up to add text to a selected tooth when charted.

Perio Chart Notes

General Perio Exam notes can easily be added in additional to Perio Chart annotations.

Ortho Chart Notes

A dedicated Ortho Chart can be used to track notes related to orthodontic treatment.

Miscellaneous Notes

General notes about the patient can be added to a text box normally displayed under the Graphical Tooth Chart.

Medical/Service Notes

General medical information or service notes can be added to a patient's medical chart, in addition to their other Medical details.

Appointment Module Notes

There are various ways to add notes that appear in the Appointments Module or on an individual Appointment.

Appointment Notes and Fields

There is a Note area in the Edit Appointment window. This allows you to add additional appointment information that can be displayed on the appointment from the schedule.

Customizable appointment fields can also be used to add appointment-specific notes.

Both Appointment Notes and Appointment Fields can be viewed and edited from the Edit Appointment window, and they can be added to appointment views to see from the schedule.

Schedule Notes

Schedule notes can be added to specific providers or employees and can be quickly referenced from the Appointments Module tabs. These are useful to indicate if someone is scheduled off, out early, etc.

More general notes about the day's schedule, like holidays or adjusted hours can be added to the schedule and are quickly referenced from the Notes indicator in the corner of the schedule area.

Provider Scheduling Notes

General information (e.g., scheduling preferences) can also be added to Provider Setup and referenced by right clicking the operatory header where the provider is scheduled.

Patient Notes

Patient notes can be placed on the schedule and can act as a reminder.

These appear similar to appointments on the schedule, but do not require you to schedule an actual appointment.

Blockouts

Blockouts can be created on the schedule to add notes or designate specific time blocks.