Paperless - Progress Notes Entry technique

[akezian]

Hello to all,
I am a new future user of Open Dental, evaluating the product and considering a conversion from Dentrix. I've been a fan of Open Dental from the beginning and very impressed with Jordan's talents and staff support.

I searched the forum on Progress Note entry and evaluated the Auto notes features. I've also used EASY NOTES, but a bit too complex and cumbersome to use. Spend hours / days setting it up to realize that the program was not solid too many bugs, thus staff did not use it .

I would like to get a system to facilitate the entry of default procedure notes as well as basic templates for the clinical notes so that the assistant can customize and pick and choose the phrases to compose the paragraph describing the procedure. I like the quick notes feature to compose the paragraph, but i would like to be able to highlight and choose one or more of the notes or phrases. I would choose set up apx 10 categories describing the beginning of the appointment to the end and have apx 6 options for each category that i can highlight and choose, If i highlighted apx 12 items or phrases, then these would all paste on the progress notes in the order the categories were presented, by just pressing the OK button.

Example : Px presents with Broken Cusp, Sensitive to Cold, Advised large Fill, Crown, 2 Carpules 2% Lidocaine,.25 CC Lido With 1/50k Epi, Shade -A1 , White Dental Lab,Advised Patient Deep fracture, may need RCT referred to DR MIN , Advised of poor perio on tooth, Signed AK31647 Assistant Janet K.

I would like to pick and choose these phrases organized in logical order and hit one button and have them copy to the progress notes

I read in the forum about "Note Scripting" enhancements from early 2008, this could be a quick solution until the other module is written

Thanks much for the feedback

Arthur Kezian

[jordansparks]

I've been promoting scripting as the solution for assembling complex notes. Radio buttons and checkboxes are part of that. Providing room for 6 radiobuttons or checkboxes for each "sentence" seems like it would fit right in with my proposal. I don't thing any "other" module would be needed.

[akezian]

Is it possible to highlight more than one item on the quick notes in one or many categories and have them paste in the progress notes, thus selecting apx 7-8 items in different sections/tabs and pressing the OK button only once. Can this easily be programmed ?

Thanks
Arthur Kezian

[jordansparks]

Yes, assembling notes in that window before exiting is easy to program. Once you are a customer, you could submit that as a request.

[akezian]

Thanks,

Appreciate the great support !

Arthur Kezian

[Rickliftig]

Hi Arthur -

My office is still in the less paper mode (not paperless yet) but we only went live with Open Dental this month. Last year I purchased EZ notes, which is a $795 porgram that does just about any combo of boxes and buttons, but found it was a lot of clicking and mousing. Now, I dictate notes into Dragon Naturally Speaking (vers. 10) and print the notes onto a full adhesive sheet. The notes are then cut and pasted into the chart. Yah - it's extra work and it probably won't be too long before I start having everyone enter into OD.

One reason that I like DNS is that I can add those essential notes without having extra buttons, ie) the patient was advised, yada yada yada. There was one case in our state (Connecticut) where a dentist being disciplined was chastised for his 'canned' notes (using Dentrix). I assume that his notes very obviously showed no variation from patient to patient.

That being said, I can read my notes now, my hand doesn't cramp up and the history is a lot clearer. At three weeks into Open Dental, I couldn't be happier. Jordan's team offers incredible support and the program is solid. I have been scanning in many letters (received and sent), photos and films and feel that it is a real time saver and organizer.

Feel free to contact me if you have any questions about my office's transition.

[fishdrzig]

Rick

I am a recent user of OD and find it more user friendly for me to still mouse click my notes in my old PM software (MOGO) and then cut and paste into Open Dental. I find this much easier then the auto notes function since I already had everything setup from MOGO and keep it running in the background anyway, very fast, very simple and very, very complete.
I am curious about the Dragon Naturally Speaking, however, could you explain in detail from start to finish how you do it? Thanks for your time.

[Rickliftig]

It's pretty simple - The secret is a full sheet label that is run through the printer.

I tend to be wordy in my notes. So I'll read:

January 15, 2009
John Smith (often has to be typed in because of Dragon's limitations)
Tooth #14. The patient's chief complaint was pain on chewing. Visually, a horizontal crack was found on the mesial buccal cusp. The pain was recreated with a fracfinder, etc. etc.

Dragon handles this stuff fairly well. It does need some training, but over several weeks it develops accuracy in the 90 percent range. One secret is using a digital mike.

So, I dictate notes on five or six patients per page, print the label sheet on the laser printer, then cut them apart with a paper cutter. I stick the in each chart and initial them.

Don't forget, DNS could easily be used to dictate directly into Open Dental. As i said, I did try ez notes, but found I was mousing and clicking way too much. It's much easier to dictate the note than to have to concentrate on the creen and cursor.

[jordansparks]

I've been told Dentrix has added a feature similar to MOGO for assembling notes. In the Dentrix feature, clicking a button starts a series of separate windows, each having multiple selections. Dentrix seems to have gotten this particular feature right, as it is not annoying. If anyone has a MOGO manual or a Dentrix manual that shows the setup and usage for this feature, I would be very interested in obtaining it or photocopies of those pages.

I'm also tempted to simply overhaul the existing Autonotes that Lukas built.

[fishdrzig]

Jordan Well, you asked for it
Below, first find a copy of a typical note copied from MOGO to OD = very legally complete = very fast to do



The patient was questioned prior to dental treatment if there has been any changes in their medications, or have they had any recent surgeries? The patient confirmed verbally that no, there has not been any changes in their medical history. The patient was asked prior to dental treatment if they have taken their Premedication as prescribed (if required). This patient does not need to be premedicated. Alternatives, benefits, costs, options and risks regarding the treatment plan were explained to the patient. Any questions the patient may have asked were answered to their satisfaction. Verbal and/or written informed consent was obtained prior to treatment. The type of crown material chosen to restore the tooth/teeth was an all porcelain crown. The shade of the crown(s) chosen was Vita Classic B4. Existing occlusal marks (if present) were noted, and a preliminary impression of the tooth/teeth to be resored was impressed with alginate and a model and temporary stent was made to create the temporary crown(s) (if needed). The type and amount of anesthetic used was prilocaine HCL 4% no vasoconstrictor 1 carpule and lidocaine HCL 2% with epinephrine 1:100,000 1 carpule. The type of injection and location of the local anesthesia that was given was inferior alveolar/lingual/long buccal @ right mandible. The local anesthesia was administered with an aspirating syringe and a a 27G short needle. Any remaining old/cracked/broken/leaking filling material and base was removed. Decay was excavated and patient informed of clinical situation. If excavated decay approximated the pulp, the patient was informed of possible future symptoms developing, necessitating possible root canal therapy and the possibility of needing to create an access opening through the crown (unless root canal therapy was previously done for the tooth/teeth to be prepared). Because enough tooth structure remained a crown buildup was not deemed necessary to retain the restoration. The material used for the buildup was none, no CBU was done @ this visit. Tooth/teeth #30 was/were prepared for crown(s) with a chamfer finish line/margin. Utilizing a soft tissue bur, a triple tray and vicostat, a final impression was taken with Affinity LV and Inflex Blue mousse fast set. A desensitizing agent was not placed on the tooth/teeth. A temporary crown(s) was/were fabricated with Temphase regular set, shade Vita Classic A3.5 and a prefabricated stent. The temporary was cemented with zinc phosphate. The temporary was adjusted to the patient's satisfaction, smoothed and polished and cleaned of all excess cement( if cement was needed and used). The patient was given verbal and/or written instructions regarding care of the temporary. The patient was dismissed with verbal instructions to avoid the area(s) with anesthesia (if administered) until the numbness had gone away. If anesthesia was administered, the patient was told to avoid hot foods and liquids, while numb, to prevent a burn. The patient was advised to contact the office if any questions or concerns regarding the treatment should arise. The patient tolerated the procedure well and left the office feeling fine. Patient was c/o pain when chewing on this tooth only a certain way, DL cusp had a fracture line present. NV= LA and insert #30, retention grooves placed in tooth, small isolite and scope used.

SJC


See the MOGO CDS (clinical documentation system) below (taken from the manual)


CDS - Getting Started
Q. What is MOGO's Clinical Documentation System?

A. MOGO's Clinical Documentation System (CDS) allows you to record accurate clinical notes with thoroughness and consistency. Customized templates and databases are attached to treatment codes according to your specific office needs.

Q. What are CDS templates?

A. CDS templates contain both the information that is the same for all patients, as well as the user-defined databases that contain the selections that will vary for each patient.

Before using the Clinical Documentation System (CDS) for the first time you will edit your ADA codes in order to create customized templates for your Clinical notes and to build your database of choices. The CDS databases will contain the information that will vary for each patient.

The CDS templates can be accessed from the Patient Lookup List under Documents and CDS Template Editor on the menu bar, and they can be accessed from the Word Processor icon drop-down arrow.

However, new CDS databases can be created and existing databases can be edited only from the CDS Template Editor under Documents on the Patient Lookup List menu bar.

When the ADA code is entered on the Patient Transaction Screen, the CDS template you created will open automatically, allowing you to document your Clinical notes. These Clinical notes are then saved in the individual patient's Notes screen under the CDS folder in the Clinical cabinet.

CDS can be activated from the Patient Transaction screen by clicking on Edit from the menu bar and selecting Auto CDS. A checkmark indicates that the CDS is turned on and that you will be documenting your Clinical notes as you enter complete dates for treatment.

You also have the option to start your Clinical documentation at a later time under Documents and CDS on the menu bar in the patient's Transaction screen.

Clinical documentation can also be entered from the Chart from Documents on the menu bar.

Tip: You can enter additional Clinical notes for a tooth from the Chart through the popup menu. Click with the right mouse and select Enter Notes for Tooth #. These notes will be added to Clinical notes along with any documentation that was done through CDS.

Rights to access and edit Clinical Notes can be set up through Passwords. Only the Supervisor can assign password rights.

The doctor can call MOGO's Support Department at 1-800-944-6646 for more information on setting up login names and passwords.

If the user has rights to "Access Clinical Documentation System", they will be able to create new templates and edit existing templates.

If you do not have this right, the CDS folder will not be shown in the Notes screen.

In addition, the Supervisor can also set up rights to "Edit Existing Clinical/QRP Documents". If you have this right, you can make changes in the patient's Notes. Of course, if HIPAA Regulations locking that has been activated in your Office Setup it will take precedence over other rights.

Spell Check is available in many areas either as a button, as an icon, or in the menu bar. Tip: You can use [F7] on the keyboard to quickly activate Spell Checking.

Spelling is on the menu bar when you are documenting CDS. The menu will list both Check Document [F7] and Configuration [Ctrl-F7]. Tip: You can use [Ctrl-F7] on the keyboard to quickly activate Spell Configuration.

Note: Only MOGO's Clinical Documentation System templates and Quick Report Processor documents use Word Processor variables. If you are printing a Quick Letter, you will use Word Processor Merge Fields to customize your letter.

Large CDS and QRP documents are compressed before being stored in the patient's Notes. This reduces the frequency of "document size" warnings received by users who embed images in these document types.

CDS Template Editor - Creating & Editing Templates
Q. What is the CDS Template Editor?

A. The CDS Template Editor is where you will customize your standard templates as well as your database list of choices for clinical documentation purposes.

The CDS Template Editor can be accessed from the Patient Lookup List under Documents on the menu bar. You can create and edit both the CDS templates and the databases from the CDS Template Editor.

Note: The CDS templates can be accessed from the Patient Lookup List under Documents and CDS Template Editor on the menu bar, and they can be accessed from the Word Processor. However, new CDS databases can be created and existing databases can be edited only from the CDS Template Editor, which is under Documents on the Patient Lookup List menu bar.

After accessing the CDS Template Editor from the Patient Lookup List, a window containing your Service Codes will appear. You will select the ADA code from this window. Note: You can customize both the standard CDS template and the database of choices if you accessed CDS from the Patient Lookup List.

Tip: You can click on the Open button at the top of the Template Editor at any time to open this list of codes again.

A CDS Template Editor window is now open. The ADA code you have selected is indicated at the top of the window.

Click on the screen and your mouse cursor will appear.

Type the information that you would like to be included as part of the standard Clinical documentation whenever this code is entered on a patient Transaction screen. This is the information that will be the same for all patients.

You can use all of the Word Processor features from the menu bar at the top of the screen. For example, you may want to change font size, margins, or color.

Note: The default size for a CDS template is Arial 10.

You will then begin creating and adding User Defined Databases to this template. The databases contain the list of choices that will vary for each patient.

After entering your standard template information for a code, you will then click on the Database button at the top of the screen to access the list of existing database titles and descriptions. Highlight an existing database title and click OK.

That database number is now on the template screen at the position of your cursor. If you made a mistake, simply delete it from the template, click on database, and select the correct database.

Tip: After customizing a template and databases, you can quickly open a database again by double clicking on it directly from the Template Editor. It is not necessary to click back on the Database button at the top of the Template Editor to search for the same database.

If you accessed the CDS template from the Word Processor, you will select the Service Code from File and Open Clinical Documentation Templates. Use the scroll bar to move through the list and click to select. Click OK.

Note: You will only be editing the template (not the databases) if you accessed CDS from the Word Processor.

Tip: You can save time by Copying and Pasting Templates.
CDS - Using Auto CDS
MOGO's Clinical Documentation System (CDS) is customized from the CDS Template Editor under Documents on the Patient Lookup List menu bar.

Auto CDS is a feature that will automatically start the Clinical Documentation System (CDS) as you enter the patient's treatment.

You have the option of documenting your clinical notes as you complete treatment or you can document your clinical notes at a later time.

Clinical notes can be documented from the Patient Transaction screen and from the Restorative Chart, as well as from the Appointment Monitor [F-12] screen.

Clinical documentation can even be used for undated treatment!

Multiple selections can be made from a CDS database by holding the [Ctrl] key when selecting.

If you would like to enter your clinical notes at the same time as treatment is dated, you will activate Auto CDS. Auto CDS will remain activated until you remove the checkmark from this option in the Transaction screen menu bar.

When you are documenting clinical notes, the bottom of the template window will display the patient name and the template that you are using.

If you cancel or close any template, you will also have icons at the top of the template that will allow you to start over again, save your existing selections, or even edit the template.

There is also a CDS menu bar at the top that will contain all of the features you can use while documenting. For example, you can access your printer setup, insert the current date and time (as well as login name) in the current template, and even send a Quick Report Processor letter.

The CDS icons are available in the toolbar.

Follow these steps to activate Auto CDS from any Transaction screen:

Click on Edit from the menu bar.

Click on Auto CDS. A check mark indicates that this feature is turned on for all patients and will remain activated until you click again to remove the check mark.

Enter dates for completed treatment and the clinical documentation windows will open automatically so that you can click to make your selections from the databases that appear.

Follow these steps to activate Auto CDS from the Restorative Chart:

Click on Documents from the menu bar.

Click on Auto CDS. A check mark indicates that this feature is turned on and will remain activated until you click again to remove the check mark.

Word Processor - Variables
MOGO Word Processor variables are only used in the following areas:

Clinical Documentation System (CDS) templates

Quick Report Processor (QRP) documents.

Messages (e.g, Recall Card messages, Appointment Reminder Card messages)

Image Template text boxes.

DO NOT USE VARIABLES IF YOU ARE CREATING WORD PROCESSOR DOCUMENTS!

If you are creating a Word Processor letter to print as a Quick Letter, you will use Merge Fields.

Variable Explanation:

Variables are symbols and letters representing a field of information from the Patient Information and Transaction screens. For example, a variable may represent the patient name or referral source. Using variables will replace those variables with specified information.

Variables are used with CDS, QRP, and Messages (e.g, Recall Messages)

Each variable begins with a pipe symbol ¦ followed by letters, numbers or other symbols.

The variables are as follows:

¦AA - Current Date (format MM-DD-YY) e.g., 12-31-08.

¦AB - Current Date (format month day, year) e.g., December 31, 2008.

¦AG - Office Title (from the employer field from the Provider list)

¦AH - he or she (appears as lower case) - this variable will automatically merge either he or she, depending on the patient's gender.

¦AI - him or her (appears as lower case) - this variable will automatically merge either him or her, depending on the patient's gender.

¦AJ - his or her (appears as lower case) - this variable will automatically merge either his or her, depending on the patient's gender.

¦AL - son or daughter - this variable will automatically merge either son or daughter, depending on the patient's gender.

Tip: You can capitalize the first letter of any variable by typing %UC1% directly preceding the variable (no spaces). For example, if you would like the word "her" to appear as "Her", you would type: %UC1%¦AJ

Appointment Reminder Card Variables:

These variables are used only for Appointment Reminder Cards, which are printed from the Appointment List:

¦AP01 Appointment Date

¦AP02 Appointment Start Time

¦AP03 Appointment End Time

¦AP04 Appointment Description

¦AP05 Appointment Provider Name

Provider Information from their Contact Information Screen:

¦B% - Provider Home Phone 1

¦B@ - Provider Home Phone 2

¦B# - Provider Home Fax

¦B$ - Provider Home E-Mail

¦B0 - (this variable is the letter B and number zero) Provider Home Cell Phone

¦B1 - Provider Home Pager

¦B2 - Provider Business Phone 1

¦B3 - Provider Business Phone 2

¦B4 - Provider Business Fax

¦B5 - Provider Business E-Mail

¦B6 - Provider Business Cell Phone

¦B7 - Provider Business Pager

Tip: You can go to the provider's Contact Information screen by clicking on the gray box in the Home Phone field on the provider editing screen.

Provider Information from the Provider Screen:

¦BA - Provider Title

¦BB - Provider First Name

¦BC - Provider First and Middle Name

¦BD - Provider Last Name

¦BE - Provider Business Address Line 1 and Line 2 (combined)

¦BF - Provider Business Address City, State, and Zip (combined)

¦BG - Provider Home Telephone (this is the home phone number on the provider information screen; it could also be the "preferred" number from their Contact Information screen)

¦BH - Provider Business Telephone (this is the business phone number on the provider information screen; it could also be the "preferred" number from their Contact Information screen)

¦BI - Provider License Number

¦BJ - Provider E.I.N or TIN Number

¦BK - Provider First and Last Name

¦BL - Provider Medicaid Number (from the top of the Provider Information screen). Use ¦BX if you want to merge the Medicaid Number from the bottom of the Provider Information screen.

¦BO - Provider Professional Title

¦BP - Provider's Employer Name

¦BQ - Provider Business Address Line 1

¦BR - Provider Business Address Line 2

¦BS - Provider Business Address City

¦BT - Provider Business Address State

¦BU - Provider Business Address Zip Code

¦BV - Provider DEA #

¦BW - Provider HIPAA #

¦BX - Provider Medicaid Number (from the bottom of the Provider Information screen). Use ¦BL if you want to merge the Medicaid Number from the top of the Provider Information screen.

Tip #1: If you enter the variables followed by %% the provider list will open so that you can select from the Provider list. For example: ¦BA%% ¦BC%% ¦BD%%

Tip #2: If you enclose the Provider's initials within a % symbol, it will pull that Provider name. For example: ¦BA%RMM% ¦BC%RMM% ¦BD%RMM% would merge the Provider whose initials were RMM.

Tip #3: Use ¦?? to open a text box anywhere within a letter. You can then type in personalized information where needed. You can add as many of these as you need. Just click cancel if you decide not to enter customized information.

Information from Patient Screen:

¦C@ Remaining Primary Insurance Benefit (from the Transaction screen)

¦C# Remaining Secondary Insurance Benefit (from the Transaction screen)

¦C% Patient's age in years only (from the birthdate field)

¦C$ The word "Premedicate" from the patient's Medical Alert field.

¦C0 - Patient's First Visit Date

¦C1 - Patient Sex

¦C3 - Case Number

¦C5 - Preferred Name (nickname)

¦C6 - Billing Name (defaults to Patient Name if field is blank)

¦C7 - Billing Title (defaults to Patient Title if field is blank)

¦C8 - Family Head

¦C9 - Medical Alert

¦CA - Patient ID number

¦CB - Patient Title

¦CC - Patient First Name

¦CD - Patient First and Middle Name

¦CE - Patient Last Name

¦CF - Patient Billing Address Line 1 and Line 2 (combined)

¦CG - Patient Billing Address City, State, and Zip (combined)

¦CH - Patient Home Telephone Number

¦CI - Patient Business Telephone Number

¦CJ - Date of Birth

¦CK - Birth Month

¦CL - Patient Social Security Number

¦CM - Medical Alert field

¦CN - Last Treatment Date (from the patient's Transaction screen; this can be used in Recall Cards)

¦CO - Medical Alert Date

¦CZ - Patient Name (First and Last Name)

Variables for Patient Appointments:

¦CU - Last Prophy Date (tracked by codes D1110 and D1120 from the Transaction screen.

¦CV - Next Prophy Appointment Date and Time (based on the Appt. type).

¦CX - Next Appointment Date and Time (does not need an Appt. type).

¦CY - Next Doctor Appointment Date and Time (based on the Appt. type).

Tip: Recall variables are used to customize Recall Card messages.

The following variables can be used in place of the "C" variables:

¦D@ Patient Billing Address Line 1

¦D# Patient Billing Address Line 2

¦D$ Patient Billing Address City

¦D1 Patient Billing Address State

¦D2 Patient Billing Address Zip Code

Tip #1: Enter %RMVBLNK% next to a variable so that you do not have a blank line if there is no information. For example: ¦D#%RMVBLNK% will not have a blank line if there is no Patient Billing Address Line #2.

Tip #2: Use ¦?? to open a text box anywhere within a letter. You can then type in personalized information where needed. You can add as many of these as you need. Just click cancel if you decide not to enter customized information.

These variables can be used for patient aged balance information:

All balances except the "Billable Amount" variable will be the same as the balances on the aging window. The "Billable Amount" variable will be the same as the Billable Amount on the Accounts Receivable report. Note: If you are using the "Skip Treatment with Insurance Pending" option, then this amount will be different than the patient balance.

¦DA - Patient Total Balance (includes insurance covered portion)

¦DB - Patient Balance (not including insurance covered portion)

¦DC - Insurance Balance (expected from insurance company)

¦DD - Current Aging Period - Amount Due

¦DE - Aging Period 1-2 - Amount Due

¦DF - Aging Period 2-3 - Amount Due

¦DG - Aging Period 3-4 - Amount Due

¦DH - Aging Period Over 4 - Amount Due

¦DI - Billable Amount (from the Billable column on the Accounts Receivable Merge Report)

These variables can be used for the patient's business address:

¦DJ - Patient Business Address Line 1

¦DK - Patient Business Address Line 2

¦DL - Patient Business Address City

¦DM - Patient Business Address State

¦DN - Patient Business Address Zip Code

Tip: Enter %RMVBLNK% next to a variable so that you do not have a blank line if there is no information. For example: ¦DK%RMVBLNK% will not have a blank line if there is no Business Address Line #2.

Patient's Family Head:

¦EA - Patient's Family Head Title

¦EB - Patient's Family Head First Name

¦EC - Patient's Family Head First Name and Middle Initial

¦ED - Patient's Family Head Last Name

¦EE - Patient's Family Head Address Line 1 and Line 2 (combined)

¦EF - Patient's Family Head Address City, State, and Zip (combined)

¦EG - Patient's Family Head Home Telephone Number

¦EH - Patient's Family Head Work Telephone Number

¦EI - Patient's Family Head Social Security Number

The following variables can be used in place of the Family Head "E" variables:

¦EK - Patient's Family Head Address Line 1

¦EL - Patient's Family Head Address Line 2

¦EM - Patient's Family Head Address City

¦EN - Patient's Family Head Address State

¦EO - Patient's Family Head Address Zip Code

Tip: Enter %RMVBLNK% next to a variable so that you do not have a blank line if there is no information. For example: ¦EL%RMVBLNK% will not have a blank line if there is no Family Head Address Line 2.

These variables can be used for family aged balance information:

¦FG - Family Total Balance (includes insurance covered portion)

¦FH - Family Balance (not including insurance covered portion)

¦FI - Family Insurance Balance (portion expected from insurance)

¦FJ - Current Aging Period - Amount Due

¦FK - Aging Period 1-2 - Amount Due

¦FL - Aging Period 2-3 - Amount Due

¦FM - Aging Period 3-4 - Amount Due

¦FN - Aging Period Over 4 - Amount Due

¦FO - Billable Amount

Family Head business address variables:

¦FP - Family Head Business Address Line 1

¦FQ - Family Head Business Address Line 2

¦FR - Family Head Business City

¦FS - Family Head Business State

¦FT - Family Head Business Zip Code

Tip: Enter %RMVBLNK% next to a variable so that you do not have a blank line if there is no information. For example: ¦FQ%RMVBLNK% will not have a blank line if there is no Business Address Line 2.

Referral letters printed from Patient Name:

The "G" variables are used when you print a letter to a patient's referral. The patient's referral is from the Referral field on their Patient Information screen. You will print the letter by selecting the patient name.

¦GA - Referral Business Title

¦GB - Referral First Name

¦GC - Referral First and Middle Name

¦GD - Referral Last Name

¦GE - Referral Business Address Line 1 and 2 (combined)

¦GF - Referral Business Address City, State, and Zip (combined)

¦GG - Referral Business Telephone

¦GH - Referral Home Address Line 1 and 2 (combined)

¦GI - Referral Home Address City, State, and Zip (combined)

¦GJ - Referral Home Telephone

¦GK - Referral Remark Line 1

¦GL - Referral Remark Line 2

¦GM - Referral Remark Line 3

¦GO - Referral Professional Title

¦GP - Patient's Referral Home Address Line 1

¦GQ - Patient's Referral Home Address Line 2

¦GR - Patient's Referral Home Address City

¦GS - Patient's Referral Home Address State

¦GT - Patient's Referral Home Address Zip Code

¦GU - Patient's Referral Business Address Line 1

¦GV - Patient's Referral Business Address Line 2

¦GW - Patient's Referral Business Address City

¦GX - Patient's Referral Business Address State

¦GY - Patient's Referral Business Address Zip

Tip: Enter %RMVBLNK% next to a variable so that you do not have a blank line if there is no information. For example: ¦GQ%RMVBLNK% will not have a blank line if there is no Referral Home Address Line 2.

These variables can be used to merge Pharmacy information:

¦HA Pharmacy Name

¦HB Pharmacy Address

¦HC Pharmacy City, State, and Zip

¦HD Pharmacy Phone 1

¦HE Pharmacy Remark 1

¦HF Pharmacy Remark 2

¦HG Pharmacy E-mail Address

These variables can be used for the patient's employer address:

¦IA - Employer Name

¦IB - Employer Address Line 1 and Line 2 (combined)

¦IC - Employer Address City, State, and Zip (combined)

¦ID - Employer Business Telephone 1

¦IE - Employer Business Telephone 2

¦IF - Fax Number (Employer Information screen)

¦IG - Remark 1

¦IH - Remark 2

These variables can also be used for the patient's employer address:

¦II - Employer Business Address Line 1

¦IJ - Employer Business Address Line 2

¦IK - Employer Business Address City

¦IL - Employer Business Address State

¦IM - Employer Business Address Zip

Tip: Enter %RMVBLNK% next to a variable so that you do not have a blank line if there is no information. For example: ¦IJ%RMVBLNK% will not have a blank line if there is no Business Address Line 2.

Insurance Information:

¦JA - Primary Insurance Company Name

¦JB - Primary Insurance Company Address Line 1 and Line 2

¦JC - Primary Insurance Company Address City, State, and Zip

¦JD - Primary Insurance Company Business Phone Number

¦JE - Primary Insurance Company Remark Line 1

¦JF - Primary Insurance Company Remark Line 2

¦JG - Primary Insurance Plan Name

¦JH - Primary Insurance Group Number

¦JI - Primary Insurance Company E-Mail

¦JK - Secondary Insurance Company Name

¦JL - Secondary Insurance Company Address Line 1 and Line 2

¦JM - Secondary Insurance Company Address City, State, and Zip

¦JN - Secondary Insurance Company Business Phone Number

¦JO - Secondary Insurance Company Remarks Line 1

¦JP - Secondary Insurance Company Remarks Line 2

Physician 1 Information:

¦LA - Physician Business Title

¦LB - Physician First Name

¦LC - Physician First Name and Middle Name

¦LD - Physician Last Name

¦LE - Physician Business Address Line 1 and Line 2 (combined)

¦LF - Physician Business Address City, State, and Zip Code (combined)

¦LG - Physician Business Telephone

¦LH - Physician Home Address Line 1 and Line 2 (combined)

¦LI - Physician Home Address City, State, and Zip (combined)

¦LJ - Physician Home Telephone

¦LK - Physician Remark Line 1

¦LL - Physician Remark Line 2

¦LM - Physician Remark Line 3

¦LO - Physician Professional Title

The following variables can be used in place of the Physician 1 "L" variables:

¦L_ Physician 1 Business Address Line 1

¦L^ Physician 1 Business Address Line 2

¦L$ Physician 1 Business Address City

¦L~ Physician 1 Business Address State

¦L! Physician 1 Business Address Zip Code

Tip: Enter %RMVBLNK% next to a variable so that you do not have a blank line if there is no information. For example: ¦L^%RMVBLNK% will not have a blank line if there is no Business Address Line 2.

Physician 2 Information:

¦L0 - Physician 2 Business Title

¦L1 - Physician 2 First Name

¦L2 - Physician 2 First and Middle Name

¦L3 - Physician 2 Last Name

¦L4 - Physician 2 Business Address Line 1 and Line 2

¦L5 - Physician 2 Business Address City, State, and Zip

¦L6 - Physician 2 Business Telephone

¦L7 - Physician 2 Home Address Line 1 and Line 2

¦L8 - Physician 2 Home Address City, State, and Zip

¦L9 - Physician 2 Home Telephone

¦LS - Physician 2 Remark Line 1

¦LT - Physician 2 Remark Line 2

¦LU - Physician 2 Remark Line 3

¦LW - Physician 2 Professional Title

The following variables can be used in place of the Physician 2 "L" variables:

¦L# Physician 2 Address Line 1

¦L% Physician 2 Address Line 2

¦L& Physician 2 City

¦L- Physician 2 State

¦L@ Physician 2 Zip Code

Referral Name:

¦NA - Referral Business Title

¦NB - Referral First Name

¦NC - Referral First and Middle Name

¦ND - Referral Last Name

¦NE - Referral Business Address Line 1 and Line 2

¦NF - Referral Business Address City, State, and Zip

¦NG - Referral Business Telephone

¦NH - Referral Home Address Line 1 and Line 2

¦NI - Referral Home Address City, State, and Zip

¦NJ - Referral Home Telephone

¦NK - Referral Remark Line 1

¦NL - Referral Remark Line 2

¦NM - Referral Remark Line 3

¦NO - Referral Professional Title

Primary Insurance:

¦OA Pri.Ins.Holder Title

¦OB Pri.Ins.Holder First Name

¦OC Pri.Ins.Holder First Name and Middle Initial

¦OD Pri.Ins.Holder Last Name

¦OE Pri.Ins.Holder Address Line 1and Line 2

¦OF Pri.Ins.Holder Address City, State, and Zip

¦OG Pri.Ins.Holder Home Telephone Number

¦OH Pri.Ins.Holder Work Telephone Number

¦OI Pri.Ins.Holder Date of Birth

¦OJ Pri.Ins.Holder Social Security Number

Secondary Insurance:

¦ON Sec.Ins.Holder Title

¦OO Sec.Ins.Holder First Name

¦OP Sec.Ins.Holder First Name and Middle Initial

¦OQ Sec.Ins.Holder Last Name

¦OR Sec.Ins.Holder Address Line 1 and Line 2

¦OS Sec.Ins.Holder Address City, State, and Zip

¦OT Sec.Ins.Holder Home Telephone Number

¦OU Sec.Ins.Holder Work Telephone Number

¦OV Sec.Ins.Holder Date of Birth

¦OW Sec.Ins.Holder Social Security Number

Contact Information:

¦PA - Patient Home Phone 1

¦PB - Patient Home Phone 2

¦PC - Patient Home Fax Number

¦PD - Patient Home E-Mail

¦PE - Patient Home Cell Phone Number

¦PF - Patient Home Pager Number

¦PG - Patient Business Phone 1

¦PH - Patient Business Phone 2

¦PI - Patient Business Fax Number

¦PJ - Patient Business E-Mail

¦PK - Patient Business Cell Phone Number

¦PL - Patient Business Pager Number

Appointment variables to show date and time separately.

¦P1 - Next appointment date in format of 12/15/07

¦P2 - Next appointment date in format of December 15, 2007

¦P3 - Next appointment starting time

Recall Variables

¦RA - Next Recall Date (Prefers Date)

¦RB - Last Activity Date

¦RC - Recall Provider Initials

¦RD - Recall Period

¦RE - Recall Unit

¦RF - Recommended Recall Date

¦RG - Recall Next Appointment

There are special Variables for Recall Card Messages that are used only for Recall cards.

Refer In/Out Variables:

¦SA = Refer In/Out Title

¦SB = Refer In/Out First Name

¦SC = Refer In/Out First Name and Middle Initial

¦SD = Refer In/Out Last Name

¦SE = Refer In/Out Business Address Line 1 and 2

¦SF = Refer In/Out Business Address City, State, and Zip

¦SG = Refer In/Out Business Telephone Number

¦SH = Refer In/Out Home Address

¦SI = Refer In/Out Home Address City, State, and Zip

¦SJ = Refer In/Out Home Telephone Number

¦SK = Refer In/Out Remark Line 1

¦SL = Refer In/Out Remark Line 2

¦SM = Refer In/Out Remark Line 3

¦SO = Refer In/Out Business Title

¦SP = The date the patient was referred out or referred in.

¦SQ = The patient's estimated return date

¦SR = The patient's return date

Keyboard functions:

[F1] - Help

Up Arrow - Moves cursor Up one line

Down Arrow- Moves cursor Down one line

Left Arrow - Moves cursor left one character

Right Arrow - Moves cursor right one character

[PgUp] Key - Moves cursor one screen-page up

[PgDn] Key - Moves cursor one screen-page down

[Home] Key - Moves cursor to the up-left corner on the screen

[End] Key - Moves cursor to the end of current line

[Del] Key - Deletes one character to the right


CDS & QRP - Using Variables
The CDS Template Editor can be accessed from the Patient Lookup List under Documents. The templates can also be accessed from MOGO's Word Processor.

Note: The CDS templates can be accessed from the Patient Lookup List under Documents and CDS Template Editor on the menu bar, and they can be accessed from the Word Processor. However, new CDS databases can be created and existing databases can be edited only from the CDS Template Editor under Documents on the Patient Lookup List menu bar.

When you create your Clinical Documentation templates, you can use all of the standard Word Processing features such as formatting and font size. In addition, you can use MOGO's Word Processor variables to customize your templates for each patient.

Note: Only MOGO's Clinical Documentation System templates and Quick Report Processor documents use Word Processor variables. If you are printing a Quick Letter, you will use Word Processor Merge Fields to customize your letter.

Here are some of the variables that you may find useful in your CDS Templates:

¦BA - Provider title.

¦BC - Provider first and middle name.

¦BD - Provider last name.

¦BA%% ¦BC%% ¦BD%% - These symbols after the provider variables will cause your provider list to open so that you can select a provider at the time you are documenting QRP or CDS.

The following variables are used only with CDS and QRP:

¦IMAGE - This variable is used to merge an image into a document. To specify the size of the image the variable can be entered along with the height and width within braces. Here is an example: ¦IMAGE{2x2} or ¦IMAGE{3x3}

¦REFOUTLIST - This will open the Refer Out database so that you can select the doctor to whom you are referring this patient. The patient will then be tracked under the Refer In/Out tab in your To Do List under the Refer Out specialty folder.

¦REFOUTLIST%ENDO% - This will open the Refer Out database, listing only those Refer Out doctors who have "Endo" as their specialty. Note: Any "specialty" name can be used within this variable. Tip: You can add your dental labs to the Refer Out database with a specialty of "Lab" and then print a lab slip when you select the lab as a Refer Out source for a patient!

¦SAVEC - MOGO will ask "Do you want to save?" Since only "saved" information can be merged into a letter, you can use this variable at any time within a template to save the documentation that is to be merged into a letter. Tip: You could then add the letters to the next database window that opens within this same template!

These variables can be used only in a QRP letter or in a CDS template (not in the user-defined databases):

¦CALENDAR - You must use upper case letters for this variable. A calendar will open so that you can select a date. The format will be as follows: 12/23/09.

This variable can be used in the CDS template (not in a user-defined database).

This variable can be used in QRP if it is enclosed in brackets as follows: [¦CALENDAR]

¦CALENDARL - You must use upper case letters for this variable. A calendar will open so that you can select a date. The format will be as follows: December 23, 2009.

This variable can be used in the CDS template (not in a user-defined database).

This variable can be used in QRP if it is enclosed in brackets as follows: [¦CALENDARL]

These variables can be used in a QRP letter or in CDS:

These variables will automatically merge tooth and surface selections that were made when the treatment was entered in a Transaction screen. Tip: If you change your CDS documents into a QRP format, these variables will also merge tooth and surface selections.

¦T# - This variable can be used in the CDS template or in the user-defined databases.

If ¦T# is used in a CDS template, the tooth number that was selected on the Transaction screen will automatically be merged into the CDS document. It will not open a tooth chart.

If ¦T# is used in the user-defined database (UDDBS), a tooth chart will open so that you can select a tooth number.

¦SURF - This variable will allow you to select a surface from a surface window. It can only be used in the CDS template (not in a user-defined database).

Click here to learn about the features in the CDS Template Editor Icons and the CDS Template Editor Menu Bar.

[jordansparks]

Yawn. Thanks though. It was nice to see how they used their variables, but I don't think your post included the actual databases feature of their CDS, which was my main interest.

[Shoagland]

I think an Auto notes overhall, or Dentrix style template would be good. I do not find it easy to make progress notes that are complete yet not time consuming,maybe this is my lack of knowledge on the best way to do it. Chartless should be quicker and thus more productive, not just easier to read. Thanks.

[atd]

For us, finding the right way to setup and enter progress notes information has been by far the most challenging part of switching to Open Dental. We're using a combination of auto notes, default procedure notes and quick paste notes to try and make it faster, but the notes are in too many places and it's too confusing for the providers. Most of the time they end up typing everything from scratch, which is time consuming. I think the main reason we're having problems with this is that we use the SOAP note format. Here are a few of the limitations/problems with the current notes:

1) Auto Notes: I like being able to customize and setup different fields to prompt users (especially for exams), but there aren't enough choices for field styles (i.e. multiple-selection list, yes/no checkboxes). Also, once you click OK on your autonote, you can't go back in and edit what you entered in the auto note form - you have to find the spot in the text where you want to add/delete/etc. Also, having quick paste notes available from the auto note would make it much better.

2) Default Procedure Notes: I like that we can customize them for individual providers. The limitation for us is that since we use SOAP notes, we end up deleting all but one of the default notes from the procedures and then combining the notes in one procedure. So there's a lot of deleting/editing.

3) Quick Paste Notes: I think these are the best option, but since we have so many different providers having the same quick paste notes for all providers doesn't work very well. It would be great if each user had their own quick paste notes category they could edit themselves, in addition to the shared quick paste notes. Manually setting up a category for each user in the current quick paste note window would be a very long list.

If anyone out there that also uses SOAP notes has any helpful ideas for me, I'd appreciate hearing them. An overhaul of the progress notes entry would make our providers very happy.

[jordansparks]

To vote, do a search for "auto note". There are two relevant feature requests:
Note scripting and logic in a simple text template
and
Auto notes overhaul

Vote for one or the other. I'm currently leaning towards overhauling existing auto notes because I'm not happy with the quality. Or, if you would rather focus on quick notes, you could submit a request for "select multiple quick notes" or something like that. In this discussion, I've also seen a possible request for "quick paste notes specific to individual users". I do realize that this means your notes would be accessible even if someone else had logged onto the computer you were on.

[fishdrzig]

The whole business with being able to write clinical notes quickly, completely and effortlessly was almost a deal breaker for me when I decided to switch to OD. Once I figured out I could still use my MOGO notes functionality to cut and paste into OD, then I decided to use OD as my main PM software. I think this is the only weak aspect of the software, the "word on the street" is that the clinical notes is a hassle,which may be a limiting factor for potential new users = fix this to run better = more users and happier present users

[jordansparks]

Then why has nobody voted for it?

[Justin Shafer]

If anyone has a MOGO manual or a Dentrix manual that shows the setup and usage for this feature, I would be very interested in obtaining it or photocopies of those pages.

I'm also tempted to simply overhaul the existing Autonotes that Lukas built.

Need any .hlp files?

[jordansparks]

Sure. That would work.

[Nate]

Before I vote could you explain what 'Note scripting and logic in a simple text template' consist of?

I graduated 4yrs ago and my dental college had their own software that allowed us to be completely digital and paperless. There were problems and it ran slow at times, but the fastest and best part of the program was entering tx notes. They were effortless. It was set up to do emergency pts in the SOAP format. Other procedures were created into one large nice note, similar to what was posted from MOGO above. Once you set complete you would go thru a series of questions regaurding the tx of each procedure. First may included did you get informed consent, did you review medical history, etc. If you did filling MO #19 then questions would included type of anesthetic used (you would select from a drop down menu), if rubber dam or cotton roll isolation was used, any liners, type of material used (Dispersalloy amalgam or TPH composite, etc). Then if you did endo your questions would include WL, Irrigation, rubber dam, etc. Once you select all the choices you would have another area where you could free hand type any additional facts. It was excellent and did not often require any additional notes. I think it was made for dummies but we appreciated it. If you could program in the majority of the question and allow us a way to edit or refine them I think it would be perfect.

The other thing was the note was all inclusive of the procedures completed that day. It listed all completed procedures first then the long extensive note came after. That is an area you would have to decide how you handle bc as of now we set each procedure complete as indviduals.

I agree it would save me alot of time, I free hand type all my notes. Most of my notes are very similar between different patients for the same procedure, even though I type them. Guess its just gettting that thought process going from start to finish with the treatment rendered.

[jordansparks]

You can already do one big long note instead of multiple separate notes. Use the procedure called "clinical note". We included it with OD having the code Zclin. I agree it's not as easy since you wouldn't have templates.

HOWEVER, I just overhauled the existing autonotes. Much more user friendly now, and ready for further enhancement later. Use the new auto notes in version 6.4 if you are after this sort of thing.

[fishdrzig]

Has anyone tried the new autonotes since the overhaul? What has changed?

[savvy]

Unless I'm locked out......version 6.4 isn't available to download yet....But I'm waiting patiently.

Cheers!!

[babysilvertooth]

Hi Arthur -

My office is still in the less paper mode (not paperless yet) but we only went live with Open Dental this month. Last year I purchased EZ notes, which is a $795 porgram that does just about any combo of boxes and buttons, but found it was a lot of clicking and mousing. Now, I dictate notes into Dragon Naturally Speaking (vers. 10) and print the notes onto a full adhesive sheet. The notes are then cut and pasted into the chart. Yah - it's extra work and it probably won't be too long before I start having everyone enter into OD.

One reason that I like DNS is that I can add those essential notes without having extra buttons, ie) the patient was advised, yada yada yada. There was one case in our state (Connecticut) where a dentist being disciplined was chastised for his 'canned' notes (using Dentrix). I assume that his notes very obviously showed no variation from patient to patient.

That being said, I can read my notes now, my hand doesn't cramp up and the history is a lot clearer. At three weeks into Open Dental, I couldn't be happier. Jordan's team offers incredible support and the program is solid. I have been scanning in many letters (received and sent), photos and films and feel that it is a real time saver and organizer.

Feel free to contact me if you have any questions about my office's transition.

can you use dragon naturally speaking directly with Open Dental?

[Rickliftig]

[/quote]can you use dragon naturally speaking directly with Open Dental?[/quote]

Yes - but now I only use autonotes as do my hygienists.i'll probably be putting up a video about it on youtube in the next several weeks.

[Rickliftig]

And I need to add -

Although very good (DNS), even 99% speech recognition leads to one error in 100 words - that's often a chart note. You don't even want to consider having your staff train on DNS --- I mean, you REALLY don't want to even consider this!

When you think about what we do in dentistry, there is a lot of repetition:

Exams can be fit into check lists
Warnings can be boilerplate
Many procedures can be entered automatically.

And then, if you have any changes or additions, you can just modify the note manually.

It works really well. Simple is best.