Tuesday, July 19, 2016

Protect Your Clinical Notes from Tampering

Keeping accurate dental records is one of the most important tasks providers are faced with. According to the ADA, "The dental team should be very meticulous and thorough in the dental office record keeping tasks. All information in the dental record should be clearly written, and the person responsible for entering new information should sign and date the entry. The information should not be ambiguous or contain many abbreviations. In practices with more than one dental practitioner, the identity of the practitioner rendering the treatment should be clearly noted in the record."

In Dentrix, providers can use the clinical notes in the Patient Chart to keep thorough, clear dental records that are signed and dated. Signing a clinical note moves it into history, meaning it can no longer be edited or deleted. However, if changes need to be made, you can post an addendum to the note.

To sign a clinical note:
  1. In the Patient Chart, select a patient.
  2. In the Clinical Notes panel, click the date of the clinical note you want to sign from the left column. The clinical note for that date appears in the middle column.
  3. Click the Sign Clinical Note button. The Sign Clinical Note dialog box appears.



  4. In the Name field, click the Search button to select the provider who is signing the note.
  5. Use the mouse or a signature pad to sign the note.
  6. Click OK. The clinical note will now have a gray background indicating that it is in history and locked from editing. The Sign Clinical Note button will now have a red ink trail behind it indicating that this note has been signed.

There may be occasions when you realize there's been a mistake in a clinical note or that the information in the note is incomplete, and you need to correct the information. If the clinical note has been signed, however, you cannot update the information in the note. In this situation you must add an addendum to the note and describe the change in a new note which will be attached to the original note.

To add an addendum to a clinical note in history:
  1. In the Patient Chart, select a patient.
  2. In the Clinical Notes panel, select the note to which you want to add an addendum.
  3. Click the New Addendum button. The New Addendum dialog box appears.








  4. Select the desired provider for the addendum by expanding the provider drop-down list.
  5. Enter the text of the desired note in the field provided, and click OK.
  6. Click Yes to the confirmation message to add the addendum to the note and return to the Clinical Notes panel.
    Note: Once you click Yes to append the clinical note in history, the addendum portion you've just written is automatically moved into history as well, and cannot be edited or deleted.
For additional information on clinical notes, see these past #DentrixTipTuesday posts:

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