Adding clinical notes

You can add a clinical note to a patient's record.

To add a clinical note

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

   

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

2. On the Chart tab of a patient's clinical record, clicktap the Clinical Notes button menu and select Add Clinical Note.

   

   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. To enter a clinical note, 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 have not assigned teeth in Step 1, the Assign teeth link displays. If you 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 - Enter a provider to associate with this note.

     If you need to add a secondary provider to the note, 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.

     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 - 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.

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

     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.

   • Note - Enter the text of the note. You can either type a free-form note or insert a note 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.

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

4. ClickTap Save.