Clinical Notes

Clinical notes are used in the EHR module to record information about patients.

There are three types of clinical notes available for use in the EHR:

  • General Note: The most basic and flexible clinical note. You can enter the contents manually or select a note code to insert pre-defined text.

  • SOAP Note: A highly structured note that contains four distinct areas to enter information: Subjective, Objective, Assessment, and Planned.

    • Each note area may be completed as a general note, allowing you to enter the contents manually or select a note code to insert pre-defined text.

  • Template Note: A pre-defined template that contains one or more tags, which behave similarly to completing a form. You can input specific information that is embedded into the form.

    • This allows you to have a highly formatted note structure with minimal manual entry.

Depending on your institution’s configuration, axiUm may require you to enter a note for every appointment, warn you if a note is missing, and prevent you from continuing until the note is added.

Notes may be associated with a patient record, a specific treatment, or a specific tooth.

Additionally, notes may be configured to auto-generate and attach to a patient’s record.

Example: When a lab order is sent/received, a note is assigned to the patient’s record.

You can add clinical notes from many places in the EHR module. Depending on how it is added, the clinical note may be a basic note, a treatment-specific note, or a tooth-specific note.

  1. Select a patient and open the EHR module.
  2. Complete any of the following to display the Note Type window:
    1. Click the Tx History tab and click the Add a new Note () icon.

      2. Tip: You can also add a basic note from the Chart Add tab or In Progress tab by clicking the Add Note () icon, or from the odontogram by clicking the Add a new Note () icon.

    1. Click the Tx History tab, the In Progress tab, or open the Chart Add tab.
    2. Right-click a treatment and select Add Tx Note…
    1. Select a tooth on the odontogram.
    2. Right-click the odontogram and select Tooth Notes/Conditions to display the Tooth Notes/Conditions window.
    3. Click the Add a new Note () icon.
  3. From the Select Note Type window, select the appropriate radio button and click OK.
    • General Note
    • SOAP Note
    • Template Notes
  4. Complete the note using the steps outlined in the sections below.
  1. Open the General Note window using a method outlined above.
  2. Complete the fields as necessary.

    3. Field Description
    Site

    If applicable, select the Site the note applies to.

    Note: If adding a tooth-specific note, this field is auto-populated.
    Date

    This defaults to the current date.

    If you have access, you can change the date as necessary.
    Phase / Seq#

    If entering a treatment-specific note, these are auto-populated with the Phase and Seq# from the treatment record.
    Tx/Note1, Tx/Note2

    These are custom fields. If configured by your institution, they display with the specified name.

    Enter the appropriate information or select from the drop-down list.

    User This defaults to the logged-in user. If you have access, you can change the user as necessary.
    Appr. User

    This displays the approval user.

    • If you do not require approval, your information displays.
    • If you require approval, this field is blank until your note is approved.
  3. Enter the note’s content using one of the following:

    • Manually enter the contents in the main text field.

    • Click the Code ellipsis to select a pre-defined note code(s).

      The note code contents display in the main text field.

      Note: If text is already in the main text field, the pre-defined text is inserted at the cursor’s location.

  4. Format the note as necessary.
    Formatting Description
    Bold

    Select a portion of text and click the Bold () icon.

    Tip: You can also press Ctrl + B to bold the text.

    Example: The selected text is bolded.

    Italics

    Select a portion of text and click the Italics () icon.

    Tip: You can also press Ctrl + I to italicize the text.

    Example: The selected text is italicized.

    Underline

    Select a portion of text and click the Underline () icon.

    Tip: You can also press Ctrl + U to underline the text.

    Example: The selected text is underlined.

    Color

    Select a portion of text, click the Color () icon, and select a color from the drop-down arrow.

    Example: The selected text displays in color.

  5. Click Add New to save the note.

    6. Note: If configured, the Check Spelling window displays, allowing you to confirm/correct spelling in the note.

  6. If necessary, obtain approval.

Note: SOAP stands for Subjective, Objective, Assessment, and Planned.

  1. Open the SOAP Note window using a method outlined above.
  2. Complete the fields as necessary.

    3. Field Description
    Date

    This defaults to the current date.

    If you have access, you can change the date as necessary.
    Tx/Note1, Tx/Note2

    These are custom fields. If configured by your institution, they display with the specified name.

    Enter the appropriate information or select from the drop-down list.

    User This defaults to the logged-in user. If you have access, you can change the user as necessary.
    Appr. User

    This displays the approval user.

    • If you do not require approval, your information displays.
    • If you require approval, this field is blank until your note is approved.
  3. Enter the note’s content using one of the following:

    • Manually enter the contents in each area.

    • Click the Code ellipsis to select a pre-defined note code(s).

      The note code contents display in the corresponding area.

      Note: If text is already in the area, the pre-defined text is inserted at the cursor’s location.

  4. Format the note text as necessary.
    Formatting Description
    Bold

    Select a portion of text and click the Bold () icon.

    Tip: You can also press Ctrl + B to bold the text.

    Example: The selected text is bolded.

    Italics

    Select a portion of text and click the Italics () icon.

    Tip: You can also press Ctrl + I to italicize the text.

    Example: The selected text is italicized.

    Underline

    Select a portion of text and click the Underline () icon.

    Tip: You can also press Ctrl + U to underline the text.

    Example: The selected text is underlined.

    Color

    Select a portion of text, click the Color () icon, and select a color from the drop-down arrow.

    Example: The selected text displays in color.

  5. Click Add New to save the note.

    6. Note: If configured, the Check Spelling window displays, allowing you to confirm/correct spelling in the note.

  6. If necessary, obtain approval.

  1. Open the Template Note window using a method outlined above.
  2. Complete the fields as necessary.

    3. Field Description
    Code

    Enter the template code for this note.

    This is used to display the framework for the note and prompts you to enter information.
    Site

    If applicable, select the Site the note applies to.

    Note: If you are adding a tooth-specific note, this field is auto-populated.
    Date

    This defaults to the current date.

    If you have access, you can change the date as necessary.
    Phase / Seq#

    If entering a treatment-specific note, these are auto-populated with the Phase and Seq# from the treatment record.
    Tx/Note1, Tx/Note2

    These are custom fields. If configured by your institution, they display with the specified name.

    Enter the appropriate information or select from the drop-down list.

    User This defaults to the logged-in user. If you have access, you can change the user as necessary.
    Appr. User

    This displays the approval user.

    • If you do not require approval, your information displays.
    • If you require approval, this field is blank until your note is approved.
  3. Enter the note’s content:

    1. Each prompt in the template will provide you space to enter the appropriate information in the Answer field.

    2. Click Next and Previous to move through the prompts and enter the content of the note.

  4. Click OK to save the note.

    5. Note: If configured, the Check Spelling window displays, allowing you to confirm/correct spelling in the note.

  5. If necessary, obtain approval.