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sonyap
Premolar III

Progress notes in charting

We are working on moving to chartless.  Right now, some of the assistants write up the charts and then the docs initial the notes and add any specifics that they want - sometimes the same day, sometimes the next day.  If we are chartless and the assistants chart the basics (anesthesia used, procedure performed, shade, etc.), is the doctor able to go back and add notes to that entry after the fact?

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Moderator
Moderator

Re: Progress notes in charting

Hello Sonya

The notes that are being added by the assistants, are they from the note button or form button? 

If it's the form button, it will depend on the option chosen for how that form saves. 

However, if it is a note, they can only be edited if it's the same day. Once that day has passed, it can will be view only.  The only option at that point would be to copy the contents from the original, paste it into a new note, add the additional information and save it, then do a correct entry on it and backdate it to the original note date. At that point you can remove the original incomplete note. 

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sonyap
Premolar III

Re: Progress notes in charting

@jdowner, it would be from the form button.  How would it need to be saved in order to allow the doctors to add personal notes to it?

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