Taking notes is a key form of communication in any dental office. Notes keep staff informed of what’s going on with a patient’s treatment, account, medical history, and more. Because there are so many categories of notes for an office, there are also many places and ways to take notes in Open Dental.
In this post, we’ll discuss creating note templates, recording clinical notes, taking notes on patient communication, notes on accounting, and more!
Note Templates
First, let’s talk about the information you seem to write over and over again. There are two ways to make note-taking more efficient.
- Quick Paste Notes
These notes allow you to quickly insert information that you use routinely. Create Quick Paste Notes for different parts of the program, including commlogs, claims, adjustments, etc. You’ll just type a shortcut and the full text will be inserted. Or you can insert the full text from a list of options. - Auto Notes
These notes are best for entering clinical notes. Set prompts for routine procedures so that you can simply select the correct information or quickly type an answer to a prompt. This also helps prevent items from being missed.
Clinical Notes
Clinical Notes can be added to a single procedure or added as a group note when you want to attach a single note to multiple procedures.
Clinical Note on a Single Procedure
If you want to enter notes when a procedure is still treatment planned or only want the note attached to a single procedure, double-click the Procedure and enter information into the Notes field.
Tech Tip: In the Edit Procedure Code window, you can set default notes to be entered automatically when treatment planning or setting complete a procedure. These can even be customized by provider.
Clinical Note on a Group of Procedures
To attach a note to multiple procedures, completed by the same provider on the same day, add a Group Note after the procedures have been set complete.
If you take notes on each procedure as you go, enable Procedure Group Notes aggregate in Preferences. Once all procedures are set complete, create the group note, and all notes from the procedures will automatically be combined into the Group Note.
Tech Tip: If you’d like notes to be separate from the procedure in the Chart, you can also create a Group Note for a single procedure.
Help! I accidentally deleted a procedure or group note!
Any time notes are changed or a procedure is deleted, they’re still available to view in the Audit View of the chart.
1. In the Chart Module, click the Show Tab.
2. Check the “Audit” box.
3. You’ll now see any deleted procedures, along with any previous versions of notes
4. Right-click the description area that displayed your lost note and select “Copy Cell Text”.
5. Uncheck “Audit” and return to the Enter Treatment Tab
6. Go to the procedure or Group Note (if the procedure or a Group Note was deleted, re-chart it first) and paste the note you copied. If at any time there were changes to the note, you’ll see multiple versions of the note when you paste. Edit the pasted text to only keep the notes you want.
Medical Notes
A number of notes related to the patient’s medical needs can be entered in the Medical section.
- Med Urgent: These notes are shown in red throughout Open Dental. Add the “MedUrgNote” row to an Appointment View to see these notes on appointments. They’ll show in the Appointment Bubble by default.
- Medical Summary: Brief notes about the patient’s medical history. These notes are displayed in the Chart Module.
- Medical History: More complex medical notes for the patient. These notes are only displayed in the Medical window, so you won’t see these details from the Chart.
- Service Notes: Useful notes about the patient’s preferences during treatment (e.g. likes a pillow, prefers bubblegum flavor). These notes are displayed in the Chart Module.
Odontogram Notes
The white box under the tooth chart is ideal for any miscellaneous notes for the patient. Changes are not tracked or logged in the Audit Trail, so they should only contain information not pertinent to the patient’s care.
Patient Communication
The best way to track communication with your patient or other patient-related (but not clinical) notes is Commlogs.
Commlogs can have specific types associated (Appointment, Insurance, Financial, Misc, etc.) Commlog Types can be customized and assigned a text color override that appears in the Account Module and Chart Module.
Commlogs can be used for the following (and more!):
- The patient called the office (e.g., to schedule or discuss treatment).
- Office staff called the patient (e.g., to discuss their account balance or treatment).
- Office staff contacted the patient’s insurance carrier (e.g., to check claim status).
Account Module
There are different areas in the Account Module to add notes for patients, claims, adjustments, and more.
Main Tab
- Fam Fin Urgent Note: Add a note that shows for the whole family (like credit card declined or check returned). These notes display in red and can also be added to appointments
- Family Financial: This area was used prior to Commlogs. We suggest using Commlogs instead, which are visible from the Account. This field can still be used if desired.
Claims
There are various fields on a claim (or Preauthorization) to record notes related to the EOB, payments, claim status etc.
In the main claim area there are several places to make notes.
- Remarks: When Receiving a Claim, enter notes about the procedure from the EOB. This is helpful if insurance underpays or substitutes a different code than you billed.
- Insurance Payment Note: When Editing or Finalizing an Insurance Payment, enter any notes about the insurance payment.
- Reasons underpaid: Enter information about why a claim was underpaid. This will show up on patient statements, which can be helpful when a patient inevitably asks why they owe more than the original estimate.
From the Status History tab, staff can add notes to track the status of a delayed or resubmitted claim.
Patient Payment Notes: If you are using an integrated credit card processor (such as EdgeExpress, PayConnect, or PaySimple) this note will auto-populate with the transaction details. Optionally, enter any notes specific to the payment. The notes can also display on a patient’s statement.
Adjustment Notes: Enter any notes about an adjustment to note why an adjustment was made or notes you’d like to show on a patient’s statement.
Miscellaneous Note Taking
Appointments
You can enter notes on an Appointment that are unique or important to that appointment.
Insurance Plan
Enter additional information about an insurance plan or a subscriber in the Edit Insurance Plan window.
- Plan Note: Enter notes specific to the plan. Helpful for benefits that aren’t tracked in Open Dental
- Subscriber Note: Enter notes specific to the subscriber. Displays for all dependents on the plan as well.
Popups
If you want staff to be alerted to information about a patient when opening an account, you can add a Popup to their account from the Main Toolbar.
Once the information in a Popup is no longer needed, it can be disabled or deleted.
Other Notes
A few more places you can add notes include:
- Administrative Notes for patient Recall: From the Edit Recall window staff can add notes related to the patient’s recall. This can include information about contact attempts, scheduling preferences, and more. Notes are also added here automatically when using Set Status in the Recall List. These notes are always reset once recall procedures are set complete.
- Referral Notes: If there are notes regarding a referral source that you want to add, there are several areas in the Edit Referral window to do this, including a Communication Log that is connected to the referral source, rather than a patient, so you can easily track communications that aren’t patient specific.
- Detailed Medical Information: Patient-specific details about Medications, Problems, or Allergies can be added to any entries that have been added to a patient.
- Mount Notes: If you’re taking radiographs in Open Dental and using Mounts, you can enter notes about the images/mount in the Mount Info window.
This isn’t an exhaustive list of the many places you can enter notes, so be on the lookout when you’re in a window and there may just be a place for notes.
Permissions
Want to lock down clinical notes so they are not edited when they shouldn’t be? Make sure only authorized users have the following. See Permissions for an explanation of each permission.
- Procedure Note (full)
- Procedure Note (same user)
- Edit Note on Completed Procedure
- Group Note Edit -(other users, signed)
- Auto/Quick Note Edit
- Commlog Create
- Commlog Edit
Preferences
Review the setup of your Preferences, to make sure notes work the way you’d like.
- Procedures Prompt For Auto Note: Determines whether unanswered prompts in an Auto Notes are triggered when a user reopens a completed procedure.
Note: Requires an auto note as the default procedure note. - Allow digital signatures: Determines whether procedure notes can be signed with a signature stamp.
- Procedure group notes aggregate: Determines how group notes combine when more than 2 procedures are added to a group note.
- Procedure notes merge together when concurrency issues occur: Determines how notes are saved when multiple users are editing the same note for the same patient at the same time.
- Notes can only be signed by providers: Determines if notes can only be signed by a user assigned to a provider or by all users.
Taking notes is a huge part of your daily tasks. Whether it be clinical notes for the patient, notes for other employees, or just little reminders for yourself, there is always a way to keep this information tidy and accessible in Open Dental.
Have questions about anything we mentioned in this post, or want to know more? Get in touch with us.
Information in this post reflects features available in Open Dental Version 24.1. For the most up-to-date information, please visit our manual.