Recording Treatment Notes

Charted Treatment can hold both Clinical and Invoice notes. You can also use the Note button to add general treatment notes that are not specific to a charted service.

Clinical Notes / Custom Screens remain editable up until midnight of the day they were charged or TC’d, after which they become read-only. This enables clinicians to process patients through the practice workflow and later write up important clinical note details. If a service is not ticked or ticked but not Charged/TC’d then the notes will remain editable until Charged/TC’d.

Entering Clinical or Invoice Notes to a charted service

Clinical Notes are intended for use within the clinic and are seen by practitioners only.
Invoice Notes print on patients Statements, Estimates, & Invoices

1. In a patient's chart tab, Double-click on the service in the Course of Treatment / Treatment Planning area

2. An Edit screen displays:

   Open

   

3. Type or use Quick Notes in the relevant tab and then click on the OK button to save.

   These notes display in the Chart tab.

   Open

   

   Notes can also be viewed in the Tooth (Treatment) History tab. “H” button

Adding General Clinical Notes using the Note Button

In addition to Clinical notes, which must be attached to a Service, the “Note” button at the bottom of the Treatment area provides the ability to create a General Note.

This is useful for recording notes when attending a patient but not actually providing any chargeable treatment, e.g., a review appointment.

1. Click the Note button at the bottom of the Charting window to open the Add Clinical Note window:

2. Type or use Quick Notes as required. Specify the Provider if this hasn’t auto-filled.

3. Send Straight to History - Tick this checkbox to send this note directly into the patient's Treatment History window so it doesn’t appear in the COT. Leave it un-ticked to list it in the Treatment Plan area below the chart.

4. Click OK. Depending on the status of the checkbox, the Note will either list in the Treatment Plan area or in the History List.

Clinical Notes / Custom Screens remain editable up until midnight of the day they were charged or TC’d. EXACT maintains an un-editable audit trail of all clinical note and custom screen creation and editing in the Tooth (Treatment) History tab. Note that Previous Notes/Voided items in the audit trail are visible when you check the Show Void checkbox in the Treatment History window:

You can optionally disable this capability for specific user groups.
Under Configure > Security, for a specified user group, open the permissions tree as follows:
File > Patients > Chart Tab > [ ] Allow Clinical Notes Editing on Charged Treatment
This permission is enabled by default, but you can un-check the checkbox to disable editing (remember to Save).

To edit Clinical Notes & Custom Screens

1. Double click the service on the COT tab on the Chart.
   If the treatment has been sent to History or TC’d then launch the Tooth (Treatment) History window using the “H” button:

2. In the Tooth History window, Locate and double-click the Clinical Note or Custom Screen, then edit it as required and click OK to save.