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A complete dental note includes several critical elements: Component. Description. Date and Time. Record of the exact date and time of the patient encounter. Personal Information. Patients name, date of birth, and contact information. Medical History. Summary of the patients medical conditions and medications.
Navigate through the service list to locate the service you require. Once located you can; Click it to highlight it then click on the appropriate tooth or surface to chart that service. Or double-click the service to chart it, a prompt will open if additional information is required.
Consider these tips before making entries in the dental record: Charting practices should be consistent in each setting and the dentist is always obligated to ensure that charting is accurate. Consider using the SOAP (Subjective, Objective, Assessment, and Plan) method for chart entries.
The most commonly used dental charting systems are: The FDI World Dental Federation notation (ISO 3950) is a double-digital system used worldwide. The first digit indicates the quadrant, and the second denotes the tooth in the quadrant. The Universal Numbering System is mostly used in the United States.
With a patient selected in Patient Chart, click the Clinical Notes tab at the bottom of the window. Next, click the Template Setup icon on the right of the panel. In the Template Setup dialog box, click New Template. This opens the New Clinical Note Template dialog box where you will create your template.
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You will need to Re-open the treatment plan using the re-open button at the bottom of the chart screen. Chart a general note, or whichever code you use to for this purpose. Expand the treatment item and make sure you set the date completed to that of the original treatment date. Add any notes needed.

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