Entering clinical notes using templates

You can quickly add a clinical note into a patient's record by using the clinical note templates available at the current location.

To enter a clinical note using a template

1. (Optional) To assign tooth numbers to a new clinical note, on a patient's clinical record > Chart or Quick Exam tab, select one or more teeth.

   

   Tip: You can also assign and/or remove teeth on the Add Clinical Note window in Step 3.

2. On a patient's clinical record > Chart tab, clicktap Clinical Notes.

   

   The Add Clinical Note window displays.

   

   Tip: To view the patient's completed and treatment-planned procedures for the selected date, clicktap the Procedures tab.

   Note: If Ascend Academic detects an unsaved clinical note for the patient that was preserved when you were previously logged out due to inactivity, the clinical note is populated with the information from the unsaved note, and a yellow warning message displays.

3. Set the following fields as necessary.

   • Th - If you assigned teeth in Step 1, the tooth numbers are automatically assigned to the note. If necessary, you can assign or remove teeth from the note by adding and/or removing the tooth numbers.

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

        

        Note: If you did not assigned teeth in Step 1, the Assign teeth link displays. If you assigned teeth, the link displays as the assigned tooth number(s), such as 2,4.

        A tooltip displays.

        

     2. To add tooth numbers, select the necessary teeth. To remove tooth numbers, deselect the teeth.

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

   • Provider - Enter a provider to associate with this 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: Only providers who have access to the current location are available.

   • Attending Provider - Enter a faculty provider to associate with the note.

     Note: Only providers who have access to the current location are available.

   • Date and Appointment - You can use these fields to associate the note with a specific date or link it to an existing appointment. By default, the note links to today's earliest appointment.

     Note: If you link to an existing appointment, the Attending provider field automatically updates to the linked appointment's attending provider. For more information, see Linking clinical notes to appointments.

     Complete any of the following:

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

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

   • Ready to sign - Set the toggle to Yes to set the clinical note as ready to sign. Set the toggle to No to set the clinical note as not ready to sign.

   • Sign as [provider's name] - This checkbox only displays when the Ready to sign toggle is set to Yes. If necessary, you can sign the new clinical note by selecting the checkbox and entering your password in the Password field.

4. Under the Templates tab, select a template category and select a template.

   

   Note: The window only displays templates available at the current location. However, the Favorites category displays templates from all of your location(s) that are marked as favorites.

5. If prompted, respond to enter more data.

   Note: If the selected template is associated with quick-pick(s), you will be prompted to enter more data.

   

   If there are multiple prompts, navigate to the next prompt by clickingtapping Next.

6. ClickTap Done.

   The finished note displays in the Note field.

   

7. ClickTap Save.