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.
Also Available: Webinar: Clinical Charting II: Clinical Notes.
Notes used with Procedures
- Procedure Notes: Use procedure notes to document anything that normally goes into your chart notes, such as materials used, procedures followed, treatment performed, anesthetic, informed consent, etc. You can optionally set up default Procedure notes (Edit Procedure Code window) that copy automatically into a procedure every time a procedure is treatment planned or set complete. Then only very minor changes usually need to be made. All procedure notes are automatically saved, changes are recorded, and all actions are archived and viewable in the Chart module under Show tab, Audit.
- Clinical Note: Some other dental software products have a clinical note, a daily note, or a procedure note. In Open Dental,
those are all just ordinary procedures that use a dummy procedure code. We include clinical note and procedure note as preconfigured procedure codes for you to pick from. These are typically set up as Procedure Buttons for faster entry.
Offices that have a data conversion may have notes from their old software placed in clinical notes.
- Procedure Group Notes: A single clinical note attached to multiple procedures by the same provider.
- Auto Notes: Templates used to insert frequently entered, large notes (e.g. for hygiene, root canals, materials, anesthetic, post op instructions). They can contain prompts and prefilled text.
General Purpose Notes
- Quick Paste Notes: Used to organize and enter frequently used notes by using templates. It is similar to Procedure Notes, but covers many different kinds of notes. Also lets you insert dates.
- Commlog: The Communications Log is at the bottom of the Account module. This is where all non-clinical patient communications should be kept. This includes Email, Patient and Referral Letters, phone calls, insurance calls, etc. Commlog notes can also be viewed in the Chart module.
- Medical/Service Notes: At the bottom of the Chart module are three note boxes: Med Urgent, Medical Summary, and Service Notes. See Medical Information for more details. The Med Urgent note can be set to show on appointments using Appointment Views.
- Tooth Chart Notes: In the Chart module under the tooth chart, there is a text box for notes.
- Family Urgent Fin Note:
Important financial notes can be entered as a Family Urgent Fin Note at the top of the Account module. This note shows in red and applies to all family members. Any changes affect all family members. The note displays when you hover over an Appointment and on the Schedule for [Patient] window.
- Family Financial notes
Appointment Module Notes
Sometimes you want notes to show in the Appointment schedule that are not part of appointments or procedures.
Patient-specific notes: 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.
- In the Appointments module, click View Pat Appts to open the Appointments for 'Patient' window.
- Click NOTE for Patient.
- Enter the note in the Patient NOTE field on the left.
- Click OK to send the note to the Pinboard, then drag the note to the schedule.
- Once the note has been handled, set it complete, or delete it.
Patient note color is set in Setup, 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.
- Create a new patient called Miscellaneous, Notes or something similar. Remember that the displayed format will be Last Name, First Name.
- Select the note patient, then Schedule an Appointment. On the Edit Appointment window, enter the note in the Appointment Note field.
To customize the general note's color, create an alternate Provider for the note (e.g. NOTE) and set the provider's color to something that makes sense in your office. Then select the NOTE provider on the Edit Appointment window for the note.
Blockouts: Blocks of time on the Appointment schedule that designate specific purposes.
Address and Phone Notes
Enter these notes on the Edit Patient Information window in the Address and Phone Notes text box. 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 will show in bold red in the Patient Information area of the Family module. These notes also show in the Unscheduled list, Recall list, and Appointment.
Notes that show on printed schedules (e.g. holidays, practice notes) can be entered in Schedule Setup.
Customize the note that shows on printed Treatment Plans.