New user, question about Progress Notes

[LeeDDS]

Hi all,

I recently joined a practice that has been using Open Dental for several years. I'm a younger doctor, and I come from a background where I have become accustomed too electronic records as the basis upon which I draw my notes, treatment plans, and consent forms.

I'm trying now to convert the office that I work at to paperless; right now, they use Open Dental purely for e-claiming to insurance and entering patient information. My first step is to incorporate progress notes in the computer rather than writing them in the paper chart...however, I've noticed that when I write notes, they can be altered or deleted at anytime. Also, when I code for say a #12 O composite, and weeks later I realize I actually did #13 O, I can easily go back and change the code.

Back when I worked in a hospital for residency, we would write our notes and then sign them. Once signed, the note cannot be altered or deleted in any way. Does Open Dental have such an option, to make the note legally-binding?

Thanks so much for any help! I'm sure there will be lots more questions to come.

-Lee, DDS

[Rickliftig]

Lee - the administrator has access to the Setup-> security menu and in there is the capability to lock out changes after a certain date. This would be a good idea not only for notes, but also for financial reasons (to deter embezzlement). And regardless, under the chart view options is a box that says audit. When this box is checked, you will see any changes made to the patient record.

I don't know what it will take to get your practice to take the next step. Perhaps, tying in a tablet computer, setting up autonotes, doing a few perio charts from it, etc, may be the 'wow' factor. I could never go back to the overstuffed charts that were drowning in illegible ink.

best,

Rick

PS - at each terminal, we have a Topaz electronic signature pad where we sign the notes (or the patient can sign the chart)

[jordansparks]

From the manual
http://www.opendental.com/manual/procedureedit.html
All notes are always saved and cannot be deleted or changed by anyone, no matter what their Permission level. But users will not notice this high security level. From their perspective, all notes can be edited, but internally, all versions of their changes get saved permanently. To see a history of all changes and deletions, use the audit checkbox in the Show section of the Chart module.

Feature request #1725:
Procedure note lock after signed or locked manually.
Create an addendum button to add changes later. While all procedure notes are already locked and secure with all historical changes preserved, it would still be more intuitive if they could appear to be "locked" in the user interface.

Your example of changing the tooth number is different. That can be blocked by ordinary security. See
http://www.opendental.com/manual/security.html