Description
This quick guide demonstrates how to add, reference and edit clinical notes, prior to the checkout, and after the checkout.
Contents
The following topics are covered in this quick guide:
- Section 1 - Adding a Clinical Note Prior to Checkout
- Section 2 - Referencing and Editing Clinical Notes
- Section 3 - Adding a Clinical Note after Checkout
Steps
Section 1 - Adding a Clinical Note Prior to Checkout
1. If not yet in the Charting module, make sure the correct patient is at the top of the Sidekick, and click Charting.
2. Prior to checkout, the clinical note is attached to the Visit on the Treatment Plan Card.
3. Locate the correct visit. It should say it is scheduled for the current date. Right-click the Visit.
4. The Visit menu opens. Click Add Note.
5. The Notes module opens where the note can be typed. Prior to checkout, the default Note Tag is Treatment Planning.
6. When the note is finished, click Save Note.
7. The note is saved on the Treatment Plan Card just under the Visit.
Section 2 - Referencing and Editing Clinical Notes
1. The note added prior to checkout can be edited. Right-click the note to open the Notes menu to access additional options, including the option to Edit note.
2. Alternatively, click the Note to expand it on the Treatment Plan card.
3. After checkout, the Visit is moved to History. Click History to change the Charting module to History mode.
4. In History, locate the Visit by Date. It will say Invoiced in the Site column.
5. In the Notes column, there is a note icon to indicate a clinical note is attached to the procedures.
6. Click the note icon to access the clinical note for that date.
7. Click the note to expand it for viewing, or right-click the Note to access the Notes menu.
8. Clinical notes are also accessible within the Sidekick. After the Visit is checked out, they can be found by sorting for Clinical History.
9. Click the note in the Sidekick to expand it, or right-click the note to access the Notes menu.
10. Clinical notes can be accessed in the Sidekick from any module by sorting the Sidekick notes to display Clinical History notes.
Section 3 - Adding a Clinical Note After Checkout
1. If the clinical note is not added prior to checkout, it can be added afterward in History mode.
2. If no note was added prior to checkout, there will be no note icon in the Notes column of the History box.
3. In the History box, right-click any of the procedures for that visit. This brings up the option to Add Note.
4. The Notes module opens. Enter the details. The Note tag is set to Clinical History by default when adding after checkout.
5. Click Save Note when the note is finished.
6. The clinical note is attached to all procedures for that date of service and will sort with the procedures if history is sorted.
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