Overview
Clinical notes are the official record of a patient's clinic visit. They're used to document and share important patient care information across the healthcare system.
Associating notes with appointments
In most health record systems, clinical notes aren't directly associated with appointments. Clinical staff infer which appointment a note is associated with by looking at the date the note was created and finding the closest appointment. If there are two appointments near the clinical note, they look at the note contents and appointment types to see which appointment the note is most likely for.
Attributes
Signed
Indicates whether the clinical note has been signed by a provider. This will be empty for health record systems where notes can't be signed.
Completed
Indicates whether the clinical note has been marked as completed. Some health record systems refer to this as “locking” the note and use this to prevent further modification. This will be empty for health record systems where the note can't be locked or marked as complete.
Supported Health Record Systems
- Dentrix
- Dentrix Enterprise
- Eaglesoft
- OpenDental