Work with Clinical Notes

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

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.

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.