Open Dental Forum

What are all of you using for hygiene visits and comprehensive exams as far as note entries are concerned? I see two good options really - auto notes and sheets. What are the pros and cons of each in the clinical setting? I'd like to follow a SOAP format.

The sheets function is what I was going to use before I really understood the system of having notes attached to procedures. I think the sheets would be easier to fill out, but would require opening it up to see it rather than a running list of all the notes and procedures. For example, I will look at the note while adding procedures.
My auto-notes have evolved to be very functional but requires going back and forth from keyboard to mouse a lot. I think another thing that steered me toward autonotes was the difficulty in creating sheets, but now it is MUCH better, making them easier to create without spending hours on end.

Some entries work well with auto notes and some with sheets! My periodic exams for example are all auto notes. However, documentation of an intra or extra oral lesion works well with a sheet. Restorations are auto notes with checkboxes.

Now for SOAP notes.... You may laugh... There I will manually type in the note. Rarely are two SOAP notes the same andI find it easier to do it longhand.

What I like too is even if you have the boilerplate entered in with an auto note, you can still alter or add to the note manually. You have incredible flexibility here.

Rather than anticipating every note you ever need,, start by establishing those notes you use repeatedly and then figure out what elements can be boilerplate, text box, etc. Over time you will quickly realize when you have to come up with a new auto note or sheet as you manually type in too much info.

Rick

I highly recommend using the exam sheet....
Before sheets were an option we used autonotes for exams. The part we didn't like is that you had to go through all the prompts at once and couldn't pause or go back and finish it later - and there were so many prompts. We recently switched to an exam sheet (which automatically opens up with the help of the automation feature!) and our staff like that much better. They still use an auto note to do the basic SOAP note for the exam, we just no longer use the exam autonote (with the ridiculous number of prompts) since all of that info is now in the exam sheet. Not only is it easier to enter, but it's easier to review later instead of reading the longhand of the autonote. As an added bonus, you can make the fields in sheets reportable! You can't do that with an autonote.

Is there documentation on how to set up exam notes

atd wrote:I As an added bonus, you can make the fields in sheets reportable! You can't do that with an autonote.

Just getting started editing reports - I'm assuming the reportable feature is a query. How do you know what the field name for a given sheet / field is? Sorry if this is a really basic question!