Editing clinical notes

You can edit a clinical note in a patient's record by replacing the current information with new information.

To edit 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 or the Clinical Note Tasks page.

   Note: Only your clinical notes display when working from the Clinical Note Tasks page.

   The Clinical Note window displays.

   

   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.

2. Complete one of the following:

   • Edit an unlocked clinical note.

     1. Modify the following fields as necessary:

     • Th - Review the assigned teeth. 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 the note does not have any assigned teeth, the Assign teeth link displays. If the note has 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 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.

       Notes:

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

       • This field is mandatory for students and other users that do not have the Sign clinical notes security right. The Save button will be disabled until an attending provider is set.

     • Date and Appointment - Review the set date or linked appointment. If necessary, edit the fields:

       • 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.

         Tip: 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 - 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.

     2. ClickTap Save.

   • Edit a locked clinical note by adding an addendum.

     Note: The clinical note is locked if you are set as the additional provider, and the attending provider or the provider already signed the note.

     1. Select the Add addendum as check box.

        The options for adding an addendum become available.

        

     2. Enter a provider in the Provider field.

        Note: If your organization has multiple locations, a provider is only available for selection if they have rights to the current location.

     3. Enter any relevant note(s) in the Addendum text field.

        Important: The addendum cannot be edited once you save it.

     4. ClickTap Save.

3. When ready, clicktap Save.