After reviewing this article, I found that five of the top 10 most frequent charting errors were in the clinical note section. Because this is such an important subject, I am going to help you avoid these potentially costly mistakes with the new Dentrix clinical note templates!
By using the new G4 clinical note templates, you can create a series of prompts that walk you and your team through all the required information as well as information that is important to your treatment coordinator for scheduling. The Dentrix clinical note templates are completely customized by you and, once you build one and understand the concept, you will love them. It might be a little hard to grasp the concept in a blog post, but I will do my best. If you want an info sheet that walks you through the steps using color-coded screen shots, drop me an e-mail at firstname.lastname@example.org and I will send it to you.
The first step is to determine the templates you will need. I recommend that you create a template for the most common procedures you perform in your office such as crowns, fillings, root canals, SRP, extractions, exams, etc. You can create a template for anything, but I suggest you start here. Next, pull out a paper chart and see what you have been writing for these procedures. This will be a good guide for you to build the text and prompts for your new electronic charting system. Next, you will need the anesthetics, materials, lab names, staff names, and any follow-up information that would go with this procedure. Once this information has all been assembled, you are ready to build your first template.
From the patient chart, click on the Clinical Note tab at the bottom of the screen. On the right side of the screen, find the icon called Template Setup and click on it. This will open the list of categories and default templates that are already pre-loaded in your system. Yes, Dentrix tries very hard to help us by creating default templates, but I have found that it is easier to start from scratch (sorry Dentrix programmers). When you click New Template, you will need to choose a category and give it a name, then you can start inserting the text and prompts. The left side of the box contains the text that will be inserted into the patient’s clinical note, and the right side has the prompts (questions) that you will answer to create the note. All of this can be explained in more detail with the info sheet I can send you if you request it through my e-mail.
After you have set up the template, it will show up in the list under the category you put it in. To initiate the template, just double click it. After you have gone through all the prompts (questions) on the template, the text will dump into your patient’s clinical note. Now you have the opportunity to edit the note, add any details, delete any items that don’t apply, or sign the note. The ADA does not require that you sign the note, but be sure to remember the note will be locked up when you run month end.