Signing clinical notes in patient records

You can review and sign a clinical note in a patient's record. Once signed, the note is locked and can no longer be edited. Depending on the note, the following providers may need to sign the note:

• Provider: The primary provider.

• Additional Provider: The secondary provider. If set, the additional provider can sign after the attending or primary provider has signed.

• Attending Provider: The faculty provider that usually supervises the treatment. This provider is mandatory for students and other users that do not have the Sign clinical notes security right.

To sign a clinical note

1. On a patient's clinical record > Progress Notes tab, select a clinical note.

   

   Tip: You can also access clinical notes from other areas such as the Chart tab.

   The Clinical Note window displays.

   

   Note: All clinical notes display the creator's name below the Note field.

2. (Optional) Edit and/or add to the note text, and change the other options as necessary.

   Note: When you edit a clinical note, the action is recorded in the Audit Log page as a Clinical Note type with 'Update' in Action.

   • Th - Review the assigned teeth. If necessary, you can assign or remove teeth from the note by adding and/or removing the tooth numbers. To add and/or remove tooth numbers, complete the following as necessary:

     1. ClickTap the Assign teeth or the assigned tooth number(s) link.

        

        Note: If the note does not have any assigned teeth, the Assign teeth link displays. If the note have assigned teeth, the link displays as the assigned tooth number(s), such as 2,4.

        A tooltip displays.

        

     2. To add tooth number(s), select the necessary teeth. To remove tooth numbers, deselect the selected teeth.

     3. When ready, clicktap X to close the tooltip.

   • Provider - Review the primary provider assigned to the note.

     If you need to add a secondary provider to the note, you can clicktap the icon to display the Additional Provider field and enter a secondary provider.

     Tip: To remove the Additional Provider field, clicktap the icon.

     Note: If your organization has multiple locations, a provider is only available for selection if they have rights to the current location. The exception to this is when a provider is associated with the appointment and no longer has access to the current location; that provider is available in the list unless you select a different provider and save the change.

   • Attending Provider - Review the faculty provider assigned to the note.

     Note: If your organization has multiple locations, a faculty provider is only available for selection if they have rights to the current location. The exception to this is when a provider is associated with the appointment and no longer has access to the current location; that provider is available in the list unless you select a different provider and save the change.

   • Date and Appointment - Review the set date or linked appointment. If necessary, edit the fields by completing any of the following:

     • To associate with a specific date, set the Date field to the date and set the Appointment field to -.

     • To link to an appointment, set the fields to the appointment's date and time.

       Note: If you link to an existing appointment, the Attending provider field automatically updates to the linked appointment's attending provider.

   • Note - Review and, if necessary, edit the note. You can also edit the note by inserting one from a template. To insert a note from a template, select a template listed under the Templates tab. If prompted, respond to enter data and then clicktap Done.

   • Ready to sign - If the toggle is set to No, set the toggle to Yes.

3. When ready, select Sign as [user name] and enter your password in the Password field.

   Tip: If Sign as [user name] is not available, set the Ready to sign toggle to Yes.

4. ClickTap Save.