Clinical notes and template notes

Write complete clinical notes to FGDP standards, use template notes, manage past notes and maintain the practice’s templates and favourites.

Who it is for: practice managers and administrators, clinicians, dental nurses.

In this guide:

1. Know what a good clinical note contains
2. Write a clinical note from the appointment
3. Find, edit, copy and print notes
4. Create and maintain template notes
5. Group template notes into favourites

1. Know what a good clinical note contains

You understand the FGDP standards for dental records and who is responsible for them.

Why this matters: the clinical record is the only evidence of what happened. GDC Standard 4.1 requires complete and accurate records, and the FGDP (UK) Clinical Examination and Record-Keeping guidance sets out what they should contain. In a complaint or claim, “if it isn’t written down, it didn’t happen”. Records must also meet UK GDPR: accurate, secure and kept for the right time (in England, typically at least 11 years for adults, and until age 25 or 11 years, whichever is longer, for children).

What a good note includes

1. Date, and who was present (clinician, nurse, chaperone, parent).
2. The presenting complaint in the patient’s words, and any medical history update.
3. Examination findings: extra-oral, intra-oral, soft tissues, BPE, caries, charting changes.
4. Radiographs: justification, grade and your report.
5. Diagnosis and the options discussed, including risks, benefits, costs and doing nothing.
6. The patient’s decision and consent (verbal or written).
7. Treatment done: tooth, anaesthetic (type, dose, batch), materials, any complications.
8. Advice given, prescriptions, referrals, and the next visit and recall interval.

Good to know

• Write notes at the time or as soon as possible afterwards. Never alter an old note to change its meaning; add a dated addition.
• Nurses often type the note while the clinician dictates. The clinician remains responsible for its content and should check it.
• Templates speed things up, but always edit them to match what actually happened. A copied template that does not match the visit is a poor record.

More detail: Patient notes.

2. Write a clinical note from the appointment

You can add a clinical note to today’s appointment and insert a template.

Why this matters: the clinical note written from the appointment is linked to that visit, so anyone reading it later sees exactly when and why it was made.

Where to find it: Create a patient note on the appointment editor toolbar, or the Notes tab › Add Patient Note.

How to

1. Click Create a patient note. Add Patient Note opens.
2. Enter a short Subject, for example Recall exam or LL6 MOD composite.
3. Choose the Type: Medical (Dental) for clinical notes; Informational, Warning or Action for alerts that pop up on future appointments; Complaint for anything the patient raises as a complaint.
4. Use Insert template to drop in one of your practice’s template notes at the cursor. Edit it so it matches what actually happened.
5. Type the rest of the note in the editor.
6. Click OK, then Save.

Good to know

• The Notes tab in the appointment only shows clinical (Medical (Dental)) notes. Patient and financial notes are on the patient record’s Notes tab.
• Use Warning sparingly, for things every team member must see (allergy, safeguarding flag, aggression). Too many pop-ups means people stop reading them.
• Complaints must also follow your practice complaints procedure (NHS complaints regulations allow 3 working days to acknowledge).

More detail: Patient notes.

3. Find, edit, copy and print notes

You can view past notes, edit or delete them (with permission) and print or copy them.

Why this matters: you’ll often need to read past notes before treating, copy a note into a referral, or print the notes for a patient’s subject access request. Under UK GDPR patients can ask for a copy of their records, and you must normally provide it within one month, free of charge.

Where to find it: the Notes tab (patient record or appointment editor).

How to

1. The list shows Made on, By, Subject and Appointment. Click a note to read it.
2. Use the copy icon on a note to copy its text to the clipboard, for example to paste into a letter.
3. Show the patient note / Print the patient note shows or prints one note.
4. Show the patient note(s) / Print the patient note(s) opens Patient Note History to show or print several.
5. To correct a note, right-click and choose Edit Note. Change it in Edit Patient Note and click OK.
6. To remove one, right-click and choose Delete Note, then confirm Are you sure you want to delete this note?

Good to know

• Edit Note and Delete Note need the Edit Patient Note permission. Most practices give it only to senior staff, because clinical records should be added to, not changed.
• Print Note and Show Note Appointment on the right-click menu are not available yet; use the print buttons instead.

More detail: Patient notes.

4. Create and maintain template notes

You can write, copy, edit and delete the practice’s template notes.

Why this matters: good templates make complete notes quick to write, for example an examination template that prompts for every FGDP item, or a consent template for extractions. Templates are shared across the practice, so a clear, agreed set raises the standard of everyone’s notes.

Where to find it: Utilities › Template Notes. You need the Edit Template Notes permission. The screen has two tabs: Notes and Favourites.

How to

1. On Notes, click the add button (Add Template Notes). In Add Template Note, give it a Name and write the Content. Use clear prompts, for example BPE: __ __ __ / __ __ __.
2. Click OK.
3. To change one, right-click it and choose Edit Template Note.
4. To make a variation, right-click and choose Copy Template Note, then edit the copy.
5. To remove one, right-click, choose Delete Template Note and confirm.
6. Click Save. If you close with unsaved changes, Save Resource asks whether to save.
7. Save & Exit (or Exit).

Good to know

• Write templates as prompts to fill in, not as finished text. A note that reads the same for every patient is not a good record.
• Agree templates at a clinical team meeting and review them yearly.
• The Knowledge Base button opens help for this screen.

More detail: Template notes.

5. Group template notes into favourites

You can create favourite groups of template notes for a clinician or type of visit.

Why this matters: a hygienist, an orthodontist and a general dentist use different templates. Grouping templates into favourites keeps the right ones together, for example an Implant review set or a Hygiene visit set.

Where to find it: Utilities › Template Notes › Favourites. You need the Edit Template Notes permission.

How to

1. Click Create New Template Note Favourite.
2. Enter a Code and Description for the group.
3. Use Code Search to find templates and move the ones you want into the group.
4. Click OK. The group’s contents are listed under Template Note Favourite Members (Name, Description).
5. To change a group, right-click it and choose Edit Template Note Favourite.
6. To remove a group, right-click it, choose Delete Template Note Favourite and confirm Yes to Are you sure you want to delete this template note favourite?
7. Save.

Good to know

• Deleting a favourite group does not delete the template notes in it.
• Keep group names short and obvious so colleagues can find them.