Capture Care Notes in Clinical Chart

Care Notes in CareStack play a vital role in a patient's clinical care by covering important information about their condition. These notes are used to record various aspects of the patient's treatment and provide convenient access to important information.

Watch this video for a complete understanding.

Let’s walk you through the simple steps to record care notes effectively.

Capture Care Notes while Charting

Let's get started!

Select the patient using the Global Search bar.

Hover over Clinical > click Chart.

Click the +Note button.

Note: The providers can view the full name of the patient while charting.

In the Notes slide-out that appears:

Use the formatting toolbar at the top to style your text.

To add implant information, click + Implant.

In the Select Implant Information modal,

Select the Implant Type from the dropdown.
Select the fields you want to include.
Click Add Details.
- The implant information will be added to the Care Note as a table.

Enter the care notes while viewing the chart.
- Press '/' to select templates for the care note.
- Press '+' to select smart phrases for the care note.
- Press '@' to select responses for the care note.

Note: The templates, smart phrases and responses are configured within the system in Practice Settings.

Hover over the items to view the following:
- Provider Name
- Tooth Selected
- Date of Appointment &
- Linked Clinical Case

Note: If you are adding notes and navigate to a different section of the system without saving, a Confirm Discard modal will appear prompting you to either select Discard or Save as Draft.

Once the required notes are added,

Click Save As Draft at the bottom to save your progress and complete the note later.
Click Close to exit.
Click the dropdown menu and select Finalize Note, to finalize the note.

Note: When you click Finalise Note, it indicates that the care note has been reviewed, all necessary information has been entered, and no further edits are needed.

Capture Care Notes in Expanded View

For increased convenience, you can capture care notes in expanded mode. To view in the expanded mode,

Click the Expand icon in the Notes slide-out.

An Add Care Note slide-out appears in the expanded view.

A box appears stating 'Press'/' for templates, '+' for smart phrases, '@' for responses'.
Followed by the text area to enter the care notes.

When a template or response is added, it displays on the left along with its corresponding responses shown on the right.

Enter your Responses for the Care Note criteria on the left.
- You will see a Green Checkmark against the completed items and a Caution icon for pending items.
You can preview your notes on the right side.
- The notes will be color-coded where completed items will be displayed in blue, In-progress items in green, and pending items in red.

Note: You can add multiple Templates or Responses if needed.

On the right of the slide-out, you can find two tabs: Patient Summary and Medical History Form.

The Patient Summary tab lets you view the patient details, such as Patient Name, Patient ID, DOB, Age and Gender, Location, Provider, Specific Date and other details.
- Select the Location, Provider, and Note date under Patient Summary.
- You can link the care note to a Tooth, Area, or Completed Code.
- You can also add details such as Tooth, Assistant, and Clinical Case if required.

The Medical History Form tab is used to view the medical history information such as Conditions, Allergies, Current Medications, Dental Questionnaire and Medical Questionnaire.
- On the very top, you can also view the patient details such as Patient Name, Patient ID, DOB, Age and Gender.