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Capture Care Notes in Clinical Chart

Aishwarya Nair
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Care Notes in CareStack play a vital role in a patient's clinical care by covering important information about their condition. These notes are used to record various aspects of the patient's treatment and provide convenient access to important information.

Let’s walk you through the simple steps to record care notes effectively.

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Capture Care Notes while Charting

Let's get started!

  • Select the intended patient using the Global Search Bar.

  • Select Clinical > Chart.

  • Click Add Notes.

In the Notes slide-out that appears:

  • Utilise the various Text Formatting options provided on the top.
  • Enter the care notes while viewing the chart.
    • Press '/' to select templates for the care note.
    • Press '+' to select smart phrases for the care note.
    • Press '@' to select responses for the care note.
Note: The templates, smart phrases and responses are configured within the system in Practice Settings.
  • Hover over the items to view the following:
    • Clinician Name
    • Tooth Selected
    • Date of Appointment
    • Linked Clinical Case &
    • Dental Assistant Name
Note: If you are adding notes and navigate to a different section of the system without saving, a Confirm Discard modal will appear prompting you to either select Discard or Save as Draft.

Once the required notes are added, you can click on Save As Draft to complete the notes later.

  • Click Close to discard the note.
  • Click on the drop-down menu to select the Finalise Note.
Note: When you click Finalise Note, it indicates that the care note has been reviewed, all necessary information has been entered, and no further edits are needed.

Care Notes in Expanded View

For increased convenience, you can capture care notes in expanded mode. To view in the expanded mode,

  • Click on Expand in the Notes slide-out.

An Add Care Note slide-out appears in the expanded view.

  • A textbox appears stating 'Press'/' for templates, '+' for smart phrases, and '@' for responses'.
  • Followed by the text area to enter the care notes.

When a Template or Response is added, it displays on the left along with its corresponding responses shown on the right.

  • Enter your Responses for the Care Note criteria on the left. 
    • You will see a Green Checkmark against the completed items and a Cautionary Icon for pending items.
  • You can preview your notes on the right-hand side.
    • The notes will be colour-coded where completed items will be displayed in blue, in-progress items in green, and pending items in red.

Note: You can add multiple Templates or Responses, if needed.

  • On the right of the slide-out, you can find two tabs: Patient Summary and Medical History Form.

  • The Patient Summary tab lets you view the patient details, such as Patient Name, Patient ID, DOB, Age and Gender, Location, Provider, Specific Date and other details. 
    • Select the Location, Provider, and Note date under Patient Summary.
    • You can link the care note to a Tooth, Area, or Completed Code.
    • You can also add details such as Tooth, Assistant, and Clinical Case, if required.
  • The Medical History Form tab is used to view the medical history information, such as Conditions,  Allergies, Current Medications, Dental Questionnaire and Medical Questionnaire. 
    • On the very top, you can also view the patient details, such as Patient Name, Patient ID, DOB, Age and Gender.
    • Click Cancel to discard the note.
    • Click Save as Draft to complete the notes later.
    • Click on Finalise to confirm that no further edits are needed.

Delete Care Notes

  • Navigate to the Notes tab on the left.

  • This will open an expanded panel; click on the arrow to collapse it down.  
  • You can filter by Date, Description and Clinician to view the desired note.

To delete a Care Note,

  • Right-click on the desired Note from the list.
  • Click Delete.

On the Warning Modal that appears,

  • Click Yes to proceed.

  • A toast notification appears stating 'Carenote deleted successfully'.

  • When a completed or finalised Care Note is deleted, it is stricken out, while notes saved as drafts are removed from the list entirely.

Note:

  • The ‘Link Note’ and ‘Add Note’ functions work in the same way. The key difference is that ‘Link Note’ allows you to add notes to a specific service code as needed. Linked notes can be found in the Notes tab even if the service is charged out and later deleted.
  • Notes added using the ‘Add Note’ function can be viewed in both the Notes tab of the Chart and the Pending Clinical Notes section. The ‘Add Note’ function is not associated with a service code.

Practices can use this quick guide to record care notes effectively as well as while viewing the odontogram. 

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