Taking notes is a key form of communication in any dental office. Notes keep the 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, security, and more!
First, let’s talk about the information you seem to write over and over and over. There are two ways to make note-taking more efficient.
- Quick Paste Notes
These notes allow you to quickly insert sentences that you use routinely. Create Quick Paste Notes for different parts of the program, including commlogs, claims, adjustments, etc.
- Auto Notes
These notes are best for entering clinical notes. Set prompts for routine procedures so that you can simply select the correct information instead of taking the time to type it. This also helps prevent items from being missed.
Clinical Note on a Single Procedure
Notes about a procedure should be placed on the Procedure itself.
Clinical Note on a Group of Procedures
If a note applies to a group of procedures, you can add a Group Note after the procedures have been set complete.
Group Notes require procedures to be set complete prior to creating the note. If you take notes on each procedure as you go, enable the preference for Procedure Group Notes aggregate in Chart Module Preferences. Once all procedures are set complete, create the group note – all notes from the procedures will automatically be combined in the group note.
Tech Tip: Help! I accidentally deleted a procedure with a note!
When a procedure with a note has accidentally been deleted, you can find the note and re-write it.
- In the Chart Module, click the Show Tab.
- Check the box for Audit.
- All deleted procedures will list. If a note was included, this will list as well.
- Take a screenshot of the note. (The Snipping Tool within Windows works great for this).
- Uncheck Audit and return to the Enter Treatment Tab.
- Re-chart the procedure, then re-type the notes from the screenshot.
A number of notes related to the patient’s medical needs can be entered in the Medical section.
- Med Urgent: These notes will show in red. These notes can also display on the appointment.
- Medical Summary: Brief medical notes for the patient. These notes show in the Chart Module.
- Medical History: More complex medical notes for the patient. These notes do not show in the Chart, so you must double-click into the Medical Area to view them.
- Service Notes: Useful notes about the patient’s preferences during treatment (e.g. likes a pillow, prefers bubblegum flavor). These notes display in the Chart Module.
The white box under the tooth chart is ideal for any miscellaneous notes for the patient. These notes are not saved or audited, so they should only contain information not pertinent to the patient’s care.
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). Types can be customized and each type can have a color. (See Definitions: Commlog Types)
Here are some reasons you might create a commlog:
- The patient called to schedule an appointment.
- You called the patient to discuss their account balance.
- You contacted the patient’s insurance carrier to discuss coverage.
There are different areas in the Account Module to add notes for patients, claims, adjustments, and more.
- 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: These notes also show for the entire family but are less urgent.
- Remarks: When Receiving a Claim, enter notes about the procedure from the EOB. This is helpful if insurance pays on a different code than you billed.
- Insurance Payment Note: When Finalizing a Payment, enter any notes about the insurance payment.
- Reasons underpaid: Enter why the insurance paid less. Useful when a patient inevitably asks why they owe more than the original estimate. This note also shows on printed statements.
- Claim note: These are notes for insurance when the claim is originally sent.
Patient Payment Notes: If you are using an integrated credit card processor (such as XCharge, Payconnect, or PaySimple) this note will auto-populate with the transaction details. Optionally, enter any notes specific to the payment.
Adjustment Notes: Enter any notes about an adjustment so you remember why the adjustment was created.
Miscellaneous Note Taking
Appointments can have appointment-specific notes entered.
The insurance plan has two spots for notes.
- Plan Note: Enter notes specific to the plan (frequencies, benefits, etc).
- Subscriber Note: Enter notes specific to the subscriber. Displays for all dependents on the plan as well.
Want to lock down clinical notes so they are not edited when they shouldn’t be? Review your user permissions. 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
In Chart Module Preferences, review your setup for notes.
- Procedures prompt for Auto Note: Determines whether prompts in an unanswered 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 electronically.
- 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 entered 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 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.