Care Notes is a documentation tool that allows dental professionals to create and maintain detailed notes about patient visits, treatment plans, procedures, and other relevant information. You can create different template categories and templates and add predefined questions as responses to create a customised note. You can also use the settings feature to do more.
Topics Covered
To create Care Notes:
Navigate to the System Menu > select Practice Settings > Clinical > Care Notes.
Manage Template Categories
To create a template category, on the Templates tab,
Click Template Categories.
On the Template Categories slide-out,
- A list of existing template categories is available to select from or Search through as needed.
- Click + Add New Category to create a new one.
- You can create new templates, such as a treatment plan template or limited oral examination template, and assign it to the Template Category you have created.
Enter the desired Name of the Template Category and click Save.
A toast notification will appear on the top right stating, 'Template Category created successfully'.
| Tip: Use the available template categories or create a template category such that you can assign single or multiple templates within the category. |
Add a New Template
Care Notes Templates serve as a guide for documenting specific aspects of a patient's condition, treatment, or progress. By using templates, you can save time and ensure that important information is captured accurately.
To add a new template,
Under the Templates tab, click + Add New Clinical Template.
On the Details tab,
- Enter the required information, such as:
- Name: Add a name to the template, e.g., Limited Oral Examination.
- Template Categories: Select your template category from the list. Learn how to create one in the Template Categories section of this article.
- Use Single Note for Multiple Teeth: Select Yes or No to create a single note for multiple teeth.
- Need Clinician Acceptance: Choose Yes or No to set Clinician Acceptance as mandatory.
- Add Responses: Add the desired response in the text box. You can also select or Search for the predefined responses you want to include in your note. To learn more, check the Responses section of the article.
- Click Save to add a new template.
A toast notification will appear on the top right stating, 'Clinical Template created successfully'.
On the Field/Form Rules tab,
You can use the Field Rules and Form Rules sections to create predefined notes with IF, IS, and IS NOT operators.
Field Rules
- Field Rules: Set single or multiple conditions and Smart Answers to create predefined notes based on your responses. Go to the Responses section of the article to learn more about responses.
-
Smart Answers: Let's say you have added 3 responses to a template, e.g., Gum Health, Teeth Condition, and Oral Hygiene. You want to populate a predefined note for Good Oral Hygiene using the responses based on Gum Health and Teeth Condition. Here is how the field rules work:
- First condition: IF Teeth Condition IS Good, no cavities or decay is selected,
- (optional) Second condition: IF Gum Health IS Healthy - pink, firm, no swelling or bleeding is selected,
- Smart Answer: Oral Hygiene AS Good is selected,
- This Smart Answer (Oral Hygiene as Good) will be automatically added to the note if the above conditions match based on the field rules.
Form Rules
Use the IF, IS, IS NOT, and OR/AND operators to set single or multiple conditions to display a pop-up note. This feature is similar to the field rules option, except here you can display a customised note. Here is how the form rules work:
- To add a Form Rule, click + Add New Rule.
- First condition: IF Teeth Condition IS Good, no cavities or decay is selected,
- (And/or) Second condition: IF Gum Health IS Healthy - pink, firm, no swelling or bleeding is selected,
- Add a default note for this condition.
- The default note will be automatically added to the patient's note if the above conditions match based on the form rules.
Manage Care Note Responses
Care Responses are placeholders that allow you to quickly complete your care notes by selecting predefined answers instead of typing them out manually each time. These response placeholders cue you to choose a response to the templated care note field, making it easier and faster to input the necessary clinical details.
On the Response tab, you can add a new custom care note response.
Click + Add New Custom Response.
-
Enter the following information:
- Name: Here you can type the required name that will be displayed for the response.
- Response Description: This content describes the response and lets users know when it should be used.
- Preceding Text: This text will appear preceding the selected responses. Example: Tooth number.
- Item Type: There are different item types you can select to customise the type of answer or response you would like to set up, e.g., Text Box to add notes, Teeth Selector to pick the position of the tooth, List to add different conditions, Date Picker to select a date, Surface, and Area of the tooth.
- Require Additional Text Area: Use the Yes or No option to mark if you require additional text area to elaborate on the response.
- Is Response Mandatory: Use the Yes or No option to make responses mandatory or optional.
- Response Type: Choose Single Response or Multiple Response as your desired response type. If you choose multiple, you can add more values.
- Use Default Value: This option will allow you to set default values for response types.
- Items: If you have selected the Item Type as List Item, you can add items by clicking +Add New Item > enter the Name of the item.
- Click Save.
A toast notification will appear on the top right stating, 'Custom Response created successfully'.
To edit a response, perform the following steps:
- Select the required response from the list or search for it in the search field.
- Click Edit.
- Make the required changes.
- Click Save.
Click here to set up Smart Answers and Smart Phrases.
Manage Settings
The settings feature allows you to customise notes during patient check-out. On the Settings tab,
Click Edit to make changes.
You can configure the following settings:
-
Enable Care Note Merge: Use the toggle to enable or disable merging multiple notes in a patient's profile.
- You can add or merge multiple notes saved as templates in a patient's profile.
- Find this option under Add Note in the clinical treatment section.
- When you are completing treatment codes for a patient, you will have the option to combine several notes triggered by those codes, helping you create one comprehensive note.
-
Appointment Settings: Under the Appointment Settings, you can decide whether to save the note as a draft or finalise it. You are provided with three options:
- Do not warn if linked notes are incomplete: This setting allows you to proceed with the linked notes in incomplete status.
- Completion of the linked note is mandatory: This setting makes the completion of the linked note mandatory to proceed.
- Warn if linked notes are incomplete: This setting displays a note to let the user know that the linked notes are incomplete, but the user can still proceed.
- The default action you select will be triggered during checkout.
- For options two and three, additional fields will be available below. You have the following sub-options:
- Notes to be Started: Tick the box to display this status during checkout.
- Notes to Review: Tick the box to display this status during checkout.
- Notes to Complete: Tick the box to display this status during checkout.
-
Print Settings: To set up the header for the Care Notes printout, configure the following under Print Settings:
- Click on the toggle button for Show Header in Print. This will enable the custom header on the care notes printout.
- You can see the Preview of the header.
- Set the Logo Alignment as intended.
- Set the Header Logo and Address to display at Account, Location, or Brand Level. Select None to avoid displaying the header logo and address.
- Click Save.
A toast notification will appear on the top right stating, 'Settings saved successfully'.
To learn how to Trigger Care Notes from Procedure Codes, click here.
Practices can use this simple guide to learn how to create care notes in CareStack.