This Standard Operating Procedure (SOP) outlines the workflow for utilizing CareStack’s Care Note templates to ensure fast, accurate, and legally compliant clinical documentation. This outlines the recommended process for using CareStack, with added context on why these steps drive efficiency. It also highlights various Care Notes scenarios to help you identify the workflow that best aligns with your practice.
Auto Populated Notes
CareStack can automatically populate Care Notes when specific codes are treatment completed or planned, helping ensure nothing is missed and saving time for your clinical team. If multiple codes apply, their templates can be combined into a single Care Note for easy review and editing. This feature is set up in your practice settings and should align with your patient workflow. (Here is a Step by Step guide to configure this in your environment)
Completed Codes: (most utilized and recommended) Best used for codes where treatment was actually performed. This way you ensure that procedures completed always have a clinical note created. You also reduce the amount of potential excess notes for patients that may have several treatment codes planned and not yet determined if the patient will complete them.
Planned Codes: Utilized to assist in ensuring proper diagnostic documentation often used in narratives at the time of exam.
Initiating a New Care Note
Starting the Care Notes after all patient intake has been reviewed is the most efficient way to record this data. Use the time before the provider exam to create the clinical note by selecting the appropriate template and entering what information you have (patient's chief complaint, vitals taken, etc.) During the exam, using the AI Scribe tool is the best way to record the provider's diagnosis and conversation with the patient. If the AI Scribe tool is not being used, this can still be manually entered during the exam using the same preset templates for ease of use.
Navigate to the Patient’s Clinical Chart.
Click the + Note button located in the upper right-hand side of the screen, right above the Care Panel box.
Alternate Scenario: If the clinician prefers to enter the clinical notes while having full view of the odontogram, they can use the Care Notes tab to the right of the Care Panel. You can access your templates & smart phrases by using the “/” and “@” command prompts inside the text box.
Template Selection & Customization
CareStack allows for automated note-building based on the specific procedures performed.
Select Templates: Choose the template(s) that match the nature of the patient’s visit (e.g., Exam, Filling, or Extraction).
Merging Templates: If a visit involves multiple procedures that require different templates, select all applicable templates and click the Merge & Add button. This combines them into a single, cohesive Care Note.
Responses: Responses are used to help reduce manual entry for common data that is routinely captured during an exam.
Smart Phrases: Can be configured in your practice settings to reduce manual data entry. Use custom phrases to auto-populate specific text inside your Care Note.
Auto Triggering Codes: (See Section #1 Above)
Completing the Note Content
Left-Hand Panel (Data Entry): Use the template fields on the left side of the screen to document treatment and diagnosis. All mandatory fields must be completed in order to save the note as a draft. Check the Mandatory tab at the top of the page.
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Right-Hand Panel (Verification): Confirm the information :
Location: Ensure the correct office location is selected.
Provider: Verify the Rendering Provider.
Date: Confirm the date of service matches the note.
Tooth Linking: Link the note to specific Tooth Numbers whenever possible. This significantly improves the ability to audit and locate specific clinical history in the future.
Alternate Scenario: If your provider prefers to link Care Notes directly to appointments, on the Link To section of the Care Note details, select Completed Code. This will tie a Care Note directly to the Appointment as long as the completed code is linked to an appointment.
Saving and Finalizing
For better oversight, set your templates to Provider Only Finalization. This prevents notes from being finalized prematurely and ensures that the Dentist of record has given final approval on all narratives, protecting the practice's clinical documentation.
Key Benefits of This Configuration:
Accuracy: Eliminates clerical errors in clinical descriptions.
Accountability: Ensures the licensed professional is the final gatekeeper of the record.
Security: Prevents accidental "locking" of notes by non-provider staff.
Reviewing Existing Care Notes (Providers)
Pending Care Notes: To review any pending Care Notes, visit your Scheduler view and click on the List’s Tab and select Pending Clinical Notes. You will have 4 tabs to sort through…
All - All clinical notes for the desired time frame.
Notes to be Started - Notes to which the user has made no responses at all.
Notes to Complete - Notes have some responses but are not completed.
Notes to Review - All Inputs were added to these notes but their review is pending
Deep Dive Tip: Care Notes should always be completed as soon as possible, before the end of the day. This ensures that critical information is not missed or overlooked and that what is contained in the Care Note is accurate. Remember, unfinalized notes can be edited and deleted. To prevent accidental edits to patient records, these should be reviewed and finalized in our last step by a provider. Finalized notes cannot be edited and as result an addendum can be used to enter additional information.
Efficiency Tips
Auto-Population: Check with your admin to see which CDT codes are linked to specific templates to automate the "Add Note" process.
Audit Readiness: Always ensure "Linked Teeth" are accurate to make the Clinical Chart more searchable during insurance claims or specialist referrals.
Pending Care Notes - Providers can easily view Clinical Notes that still need a provider to Finalize. From the scheduler view, select the List section and select the Pending Clinical Notes tab.