It’s important to add the space so that when you insert your prompt there is a space between the end of the question text and the beginning of the text that is inserted through the prompt. Type the first question words, “Images taken”, followed by a colon and a space. In the Clinical Note Text area, type “Patient was seen for a new patient exam.” Then press ENTER to begin a new line. In the Template Name field, type New Patient Exam. Since we’re setting up a template for new patient exams, select the Clinical Exams category. This opens the New Clinical Note Template dialog box where you will create your template. Next, click the Template Setup icon on the right of the panel. With a patient selected in Patient Chart, click the Clinical Notes tab at the bottom of the window. Follow the steps below to design a New Patient Exam template that you can use for clinical notes during every new patient exam. Exercise: Designing a Templateįor practice, let’s create a template in Dentrix. Now that software can automatically enter the complete word-making it easier for people to understand what you mean-abbreviations are not necessary. In the past, when clinical notes were all handwritten, the healthcare system allowed for abbreviations so that doctors or hygienists didn’t have to waste time writing out every word. For example, does CC in the example above stand for Carbon Copy, Continuing Care, or Chief Complaint? The answer is Chief Complaint. Using Clinical Note templates also eliminates the need for abbreviations, which can be confusing and may mean different things to different people. I think about clinical note templates according to the 90/10 rule: the 90 percent of text I write for every new patient exam–text that never changes–is work the computer can do the information I change for each patient is usually only about 10 percent. The other lines identify other clinical note details that will be recorded during each new patient exam. It’s the answers that change from patient to patient.īecause these clinical notes are for a new patient exam, this first line will never change. To illustrate this, let’s begin by looking at some typical new patient exam notes, which might look something like this:įor consistency, the questions for a new patient exam should always remain the same. The prompts allow you to enter custom information that will vary patient by patient. The note text is always the same every time you use that template. Templates are made up of note text and prompts. You can use and customize those, or you can design your own templates. How Clinical Note Templates Workĭentrix comes with several clinical note templates already created. With clinical note templates, you can also read all your clinical notes from any computer, and you can sign and lock the notes into history. (Have you ever noticed the many different ways people spell hygiene?) They can also save you time! You can accurately record several paragraphs of patient notes in just a few minutes without typing every word of a long note. Clinical note templates can also help prevent spelling errors. Using clinical note templates, all the doctors and hygienists can easily record specific details in their clinical notes while maintaining the important consistency, accuracy, and legibility that’s often missing from handwritten notes. Since providers’ time is one of the most valuable commodities in the dental office, how can you ensure that you’re getting detailed notes without wasting provider time? Clinical note templates is the answer. Updated 1/13/21ĭocumenting treatment and exams in order to create a complete clinical record is an important part of each appointment, but creating detailed clinical notes takes time. Use clinical note templates to save your providers time and help them create thorough, consistent clinical notes.
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