Are you using the Dentrix clinical note templates? This is a great way to add in a templated prompt, so your team will be asked about the results of the oral cancer screening. It is so easy and so important to provide good documentation for your patient’s record.
If you are using a template for your hygiene visit, you can add two questions into your clinical note template that will give your clinical team a consistent and complete account of the OCS. Go to the Patient Chart > Clinical Notes > click on the Template Setup to open your templates. Many of these templates might be from the Dentrix initial installation so you will be editing an existing template or creating a new one.
If you have an existing template, you want to add the OCS prompts then select your template and click on Edit Template. Now you can add in a new prompt that will ask you how you performed the oral cancer screening (visual exam, Velscope, other) and what the results were (negative, no findings, refer to oral surgeon, etc.). You can create prompts with check boxes or create a prompt with a text box that will give you space to write in specific findings.
If you are creating a new template specifically for the oral cancer screening, then click on New Template and start from scratch. When creating a new template, the left side of the window is where you will type in all the “static” text you want in all your notes and the right side of the set-up window is where you will add in your prompts. You can set up prompts as check boxes, text boxes, etc.
Having thorough clinical documentation is critical to the integrity of your patient record and will protect you during a lawsuit or complaint to the licensing board. It is extremely important that you have a well-documented patient chart. The clinical note template is one way to accomplish this.
Dayna loves her work. She has over 25 years of experience in the dental industry, and she’s passionate about building efficient, consistent, and secure practice management systems. Dayna knows that your entire day revolves around your practice management software—the better you learn to use it, the more productive and stress-free your office will be. In 2016, Dayna founded Novonee ™, The Premier Dentrix Community, to help cultivate Dentrix super-users all over the country. Learn more from Dayna at www.novonee.com and contact Dayna at firstname.lastname@example.org.