Your clinical note is part of your legal documentation for your patient’s chart. When I say, “legal documentation,” to me, this means that it cannot be deleted or altered without some kind of security feature in place. There are only a few places in Dentrix that I consider “part of the legal documentation” and the clinical note is one of those places. So what exactly happens to make it a secure place to make clinical notes and what happens if you need to edit a note or back date a note?

First, it is important to know that the clinical note will be locked into history if you sign the note or you run the month end process. If you need to alter the clinical note after it has been secured, the only way to do this is with an Addendum. The Addendum will attach itself directly to the original note with today’s date. After you have saved this Addendum, it is also locked up into history and cannot be altered or deleted. If you ever need to print out your patient’s clinical notes, you will see the date of entry and the date of the Addendum.

Now, there may be times when you will need to back date a note. For example, if the doctor comes in the office on the weekend to see a patient and he does not write up the clinical note on that day, he will need to back date the note. Another example might be if you forgot to write up your clinical note for a patient visit (we are all human) and you need to back date it. If you are back dating a clinical note into a month that has already been closed out, your note will automatically be secured into history. Also, if you back date a note, it will show the date it was created and the date it was backdated to. See image below.

Knowing how your clinical note documentation will present when printed is important to know if and when you need to show your clinical documentation. The Dentrix software does a great job to show the dates and times so you can feel confident in the integrity of your clinical documentation.