Clinical notes
Write, save, and lock clinical notes during a visit.
Overview
Clinical notes are the dentist's running narrative for each visit — chief complaint, examination findings, treatment performed, post-op instructions. They're lockable for legal reasons; once locked, only amendments can be added.
Prerequisites
- Clinical role
- An active consultation (or write a free-standing note via patient profile)
Steps
Open the consultation form. Top nav Consultations → row, or via Queue → Start visit.
Switch to the Notes tab.
Pick a template (optional). Templates speed up routine visits — Hygiene, Restorative, Endo, etc. Insert and edit.
Write the note body. Free-text editor with sections: Chief Complaint, History, Examination, Diagnosis, Treatment, Post-op.
Insert structured snippets. Drug name autocompletes; CDT code autocompletes; teeth charted today auto-link.
Autosave is on. A Saved <time> indicator at the top updates as you type.
Mark draft or publish. Draft is your private working copy; Published shows in the patient's clinical record. Publish before consultation completion.
Lock at consultation completion. Completing the visit auto-locks the note. After lock, edits aren't permitted; use amendments.
Expected outcome
- A
ClinicalNoterecord per visit, status DRAFT orPUBLISHED - After completion: locked, only amendable
- Note appears on patient profile Notes tab and in audit log
Troubleshooting
| Symptom | Likely cause | Fix |
|---|---|---|
| Autosave didn't save | Network blip | Click manual save; the indicator shows last successful save |
| Template insert wiped your text | Replace mode | Use Insert mode; or undo |
| Locked note has typo | After lock, edit isn't allowed | Add an amendment |
| Note missing from patient profile | Still in draft | Publish from the consultation Notes tab |
| Want to copy text from old note | Open old note → Copy | Paste into new; preserves traceability |