Hygiene Notes

Hygiene Notes

When the patient appointment is complete, notes about the appointment must be made. The templates with prompts are the preferred method. This provides the doctor’s with uniform order when they are attempting to read the information.

Expectation is that notes for hygiene are completed before the patient leaves their appointment.

Always try to capture clinically relevant information and document what happened during the appointment. Remember this is our only legal record of what happened during the patient appointment. Sometimes it is necessary to document specific discussions with the patient. Use professional language. If more documentation regarding the appointment is necessary – patient behavior, specific details about the patient’s life – utilize a Comm Log or Add/phr note in the Patient Information tab.

It is important that you have studied K&A list of acronyms and use only those acronyms in your chart to help with consistent communication throughout the office.

The notes having varying amounts of information needed depending on the procedure. Below is the example for adult prophylaxis.

Adult prophylaxis

After the patient is checked out.
Click on the chart area of the patient’s record.
Highlight procedures that were completed by hygienist and right click on highlighted area.
Select group note, auto note and select procedure that was completed. ie. recare
Click through the prompts, and complete the boxes
Modify answers if needed after you have clicked through all responses
Sign digitally at the end and <press E> in the top left of the signature box

Child Prophy

After the patient is checked out.
Click on the chart area of patient’s record
Highlight procedures that were completed by hygienist and right click on highlighted area.
Select group note, auto note and select child prophy,
Click through the prompts, and complete the boxes.
Modify answers if needed after you have clicked through all responses
Sign digitally at end by clicking on E in the top left of signature box.
SRP
In chart, click on <description of quadrants> and choose autonote, then SRP on the left side. Select the prompts, then modify information after, for example anesthesia given and by whom.
Sign digitally at the end and <press E> in the top left of the signature box

Nitrous

Click on notes and choose nitrous on the left side
Select prompts to input percentage of nitrous used and the time administered. Sign digitally at the end and <press E> in the top left of the signature box.

Perio maintenance

Click through prompts including evaluation for frequency of recall.
Sign digitally at the end and <press E> in the top left of the signature box.

**When using prompts in the AutoNote, please delete prompts that you do not use. If something is left incomplete – it is assumed that you did not complete that item during your appointment. The record is not accurate if you leave the prompt.