Appointments and charting

An appointment links a patient to a dentist with an appointment type and the scheduled, start and end times. It moves through scheduled, arrived, in progress, awaiting review and completed, or is cancelled. The coordinator records the patient’s arrival and the start of the visit, so the team can review each visit by its recorded state.

During the visit the licensed clinician writes chart notes against the appointment. Each note has a note type, the text, the author and a status of draft, signed or amended. The clinician records the signing date when signing a note. A later correction can be marked Amended; agree how the practice retains and reviews prior content. Clinical measurements, such as pocket depths, blood pressure before sedation or mobility grades, are recorded against the same appointment with value, unit, time and who measured them.

When the visit is finished, the coordinator sends it for review. The clinical reviewer checks the notes, measurements and other evidence before the visit is completed.

The coordinator runs the schedule; clinicians document; the reviewer checks before completion.

• Status that follows the visit. Scheduled, arrived, in progress, awaiting review, completed.
• Signed, then amended. Review corrections to signed notes.
• Measurements with units. Every value has its unit, time and author.

Agree your appointment types and how long each is scheduled for. Agree which note types are required for which visits, how soon after a visit notes must be signed and who may amend a signed note. List the measurements you record and their units. Decide which visits need review before completion. Prepare examples of a routine check-up, a visit with an amended note and a cancelled appointment.

A patient arrives at 9:52 for a 10:00 scaling. The coordinator marks her arrived, and at 10:04 Dr Lim starts the visit. Dr Lim records six pocket depths in millimetres and writes a periodontal note, signed at 10:41. The coordinator sends the visit for review.

The next morning Dr Lim realizes one depth was recorded on the wrong tooth. She marks the note Amended and follows the practice’s correction procedure for the earlier signed content. The reviewer communicates the decision, and the coordinator records the completed visit with its actual end time.

• Appointment board — Today’s visits grouped by status, from scheduled to awaiting review.
• Appointment schedule — Visits with patient, dentist and scheduled, start and end times.
• Chart notes to sign — Draft notes waiting for the author’s signature.

• Intake to review: From arrival to a completed visit.

Check the data model before importing appointments.