You can chart completed, planned, and existing treatment in a patient's clinical chart.
Note: A completed procedure charted in the clinical chart appears in the clinical record and financial ledger; however, a treatment-planned procedure or existing condition does not appear in the financial ledger.
To chart treatment
How to get there
Use the Patient Search box to access a patient's record.
If the last patient record you accessed since you last logged on is the correct patient's record, you do not need to re-enter the patient's name in the Patient Search box.
You can include inactive patients in the search results by setting the Include inactive patients switch to On.
On the Patient menu, under Clinical, click (or tap) Chart.
The patient's clinical record opens with the Chart tab selected.
On the Chart tab of a patient's clinical record, select one or more teeth.
Click (or tap) Add Procedure to select the appropriate procedure, surfaces (if applicable), and provider from the Add Procedure dialogue box.
In the Add Procedure dialogue box, do the following:
Click (or tap), , or .
Make sure the correct provider is selected for this charting session. Only providers who have access to the current location are available. Changing the provider may change which options are available in the procedure filter list (which is next to the Available procedure search box) and, consequently, may change which procedures are available on the Tx Plan and Completed tabs.
On the Tx Plan or Completed tab, procedures appear in the list according to the selected filter.
Select one of the following filters from the list next to the Available procedure search box as needed:
NHS procedures - If the patient is an NHS patient, NHS procedures is selected by default. With this option selected, only procedures that have an NHS Clinical Data Set Default specified are available.
Third-Party procedures - If the patient is not an NHS patient but has an active third party attached to his or her record, and if the selected Provider is contracted with the patient's third party, Third-Party procedures is selected by default. With this option selected, only the third party's allowed procedures are available.
Location procedures - If the patient is not an NHS patient and is not covered by a third party that the provider is contracted with, Location procedures is selected by default. With this option selected, only the location's allowed procedures are available.
Note: NHS procedures is available only if the patient is an NHS patient. Third-Party procedures is available only if the patient has an active third party attached to his or her record, and if the selected Provider is contracted with the patient's third party. Location procedures is available for any patient.
Search for a procedure using one of the following methods:
Click (or tap) in the Available procedure search box (on the Tx Plan or Completed tab) or in the Procedure Search box (on the Existing tab), and begin typing part of the procedure description (for example, "ama" for Amalgam Filling 1 Surface) or code (for example, "FIL" for FIL-AMLS1). The procedures that match the criteria entered appear in the list. Continue typing as needed to narrow the results.
While viewing the procedure list by the Top procedures (the most common procedure types for the selected tooth, arch, or quadrant or for the full mouth), locate a procedure.
While viewing the procedure list by the View by categories option (the procedures for the selected tooth, arch, or quadrant or for the full mouth are grouped by category), click (or tap) a category to view the corresponding procedures.
Note: Procedures appear in the procedure list according to which teeth or if any teeth are selected. For example, if no teeth are selected (the treatment area is the mouth) and you perform a search for "amalgam," no procedures will appear in the list; similarly, if no teeth are selected, an amalgam, procedure will not appear in the list of top procedures or within a category (if you are viewing procedures by categories).
Click (or tap) a procedure.
Important: If you chart a multi-code that includes some procedures that are not allowed by the NHS, the location, or the patient's third party, those procedures will not be posted.
If applicable, in the Select Surfaces dialogue box that appears, select the surfaces on each tooth for the selected procedure, and then click (or tap) Done.
To navigate between teeth, click (or tap) a Th. Alternatively, click (or tap) Back and Next.
To not enter surfaces for the selected tooth, set Exclude tooth to On.
To set Class 5 to On, at least one of the appropriate Surfaces must be selected: mesial, distal, lingual, or facial/buccal.
To apply a common combination of surfaces, under Surface combinations, click (or tap) the appropriate button.
You can edit the procedure as needed (such as to enter a supernumerary tooth number or to attach diagnosis codes).
Note: The charge that is used for a charted or scheduled procedure comes from either the provider's fee schedule or, if not applicable, the preferred fee schedule of the location where the procedure was charted or scheduled.