🚨 Important - This guide is only suitable for users on the closed beta for the new clinical notes experience in Dentally. This feature will be the only way of creating clinical notes in Dentally across all practices in the new future.
If you are interested in joining our group of early access beta users to help shape how this tools works - register your interest here.
📝Please note - Only Level 2 practitioners and above can create, dictate, lock and amend clinical notes.
As you use this guide to assist in your clinical note documentation its important to remember that AI summaries are intended to assist with documentation, not replace clinical judgement. It is you responsibility to review all AI generated notes carefully to ensure they accurately reflect the appointment and your own clinical opinion before saving.
How to access the clinical note sidebar
Clinical notes are saved against each appointment on the patients treatment plan.
To start writing your notes click 'Create note' or click on the 'Open clinical notes sidebar' button across the top of the patient's current appt.
📝 Please Note - If you haven't tried dictating with AI notes before we recommend trying AI notes with a test patient first. Take a moment to try different microphones, accent settings, and locations across your practice to see what gives you the best results.
How to select a clinical note template
This is an optional step when using the note sidebar to create, dictate or summarise clinical notes.
Click '+ Add a template' or use '/insert template shortcut' to add your preferred template
To see your practice templates make sure you have enabled them for use with AI notes.
💡 Top Tip - Although optional, using templates to guide your note-taking enables you to created structured notes every time. Take a look at our best practice guidance for optimising your templates for use with AI notes.
How to record an appointment with Ambient Listening
Ambient Listening does not save the verbal recording of your appointments. It records the transcript of your conversation with the patient against your appointment notes - and allows you to summarise your transcript into structure notes.
Open the clinical note sidebar for the appointment in question
Select a template to ensure structured clinical notes upon summarising with AI.
🚨 Important - Before proceeding it is crucial you have obtained verbal or written consent from your patient to record the transcription of their appointment.
Click the microphone button on the clinical note sidebar to start recording.
Any speech will appear in the transcript window and will be saved here against the note for future reference.
💡 Top tip - You or your nurse/dental assistant can manually type notes into the editor whilst the recording and transcript continue to ensure no important details are missed.
There is no need to format your speech, simply speak naturally with the patient and the AI will handle the formatting of your clinical notes for you when it generates a summary from your conversation with the patient.
Use the 'Stop' and 'Resume' buttons in the transcript window as many times as you need throughout your appointment.
When your finished with the appointment transcript and have jotted down any details needed in the note editor you are ready to generate an ai note summary.
How to dictate my notes without recording the appointment
If you do not want to record your entire appointment with Ambient Listening, you can still dictate your notes post appointment and use the built in AI technology to summarise your transcript into a structured clinical note - without the hassle of manually typing up your notes.
Open the clinical note sidebar for the appointment in question
Select a template to ensure structured clinical notes upon summarising with AI.
Click the microphone button on the clinical note sidebar to start recording.
Simply speak naturally - don't worry is you stumble over your words as the AI will format this for you later.
Your dictated notes will appear in the transcript window and will also be saved here against the note for future reference.
You can manually type notes into the editor as well as speaking your notes.
Use the 'Stop' and 'Resume' buttons as many times as you need throughout your dictation.
When your finished dictating your notes you are ready to generate an ai note summary.
💡 Top Tip - Use your template as a script, to say everything you need to about each patient. Take a look at our guide on how to speak to AI for the best outcomes every time.
How to write a clinical note without using AI
Don't want to use AI in your clinical workflow? no problem, you can still use the clinical notes sidebar to type your notes as normal.
Open the clinical note sidebar for the appointment in question
Select a template to work from as you type up your notes.
Use the note editor in the clinical sidebar to start writing your notes.
You can highlight text or use the '/' menu to add formatting to your note as you type.
When your finished typing it's important to remember to sign and lock your clinical note.
What is the difference between AI notes and ambient listening?
Although AI notes and ambient listening work really well together, they can be used separately to suit your clinical note taking needs.
Clinical notes can be typed, signed and locked without the use of either AI notes or ambient listening. However, these advanced tools help make your daily admin workflows easier than ever.
What are AI notes?
AI notes is a feature that takes your own dictation, templates, and manual/typed input and turns this into a structured clinical note using AI.
AI notes focuses on producing the written clinical record for you to save against the patient's clinical history. You remain responsible for reviewing, editing, and approving the content before signing.
What is ambient listening?
Ambient listening is an appointment recording and transcription tool. It:
Captures the conversation between clinician and patient
Produces a searchable, saved transcript
Allows you to resume recording during or after the appointment
Ambient listening does not write or finalise your clinical notes. It simply captures spoken content into the transcript saved against the clinical note.
How they work together
Ambient listening records and transcribes the conversation throughout the appointment.
AI notes uses that transcript (along with any additional input like typed notes or dictation outside or appointment recording) to generate a structured clinical note.
You as the practitioner then have the responsibility to review, edit, sign and lock the note.
You can use these tools in a multitude of ways:
Use ambient listening without generating an AI note.
Use ambient listening and use AI summaries to generate a clinical note.
Use dictation to speak your notes after an appointment and use AI summaries to generate a clinical note.
Manually type your notes for a more traditional note taking experience without using either AI notes or ambient listening.
How to generate a clinical AI note summary
Once you have finished typing, dictating, or recording your appointment. You can use our built-in AI technology to create a structured summary of your input.
When you are ready to generate a clinical note:
Select the 'Generate summary' button - which looks like three stars.
Wait a moment for the note to be produced - this can take a few seconds.
If you have a template selected it will use this as a guide to structure your transcript or drafts into a finalised clinical note
🚨Important - You should always double-check your AI summaries for accuracy. Since AI tools can misinterpret information, always take a moment to verify that the generated notes correctly reflect what was observed during your appointment.
After checking over the output from the AI summary and making any edits needed - simply sign and lock your note.
How to sign and lock my clinical notes
Once you are happy you have captured all the information about the appointment, you must click 'Sign and lock' to complete your note.
This step ensures the original note is saved safely against the patients appointment and in the patient's history.
After clicking 'Sign and lock' you will see that the note is now marked with who and when it was signed and locked by.
Missed something? You can make amendments after signing and locking your note using the 'Add amendment' button at the bottom of the note sidebar.
How to format clinical notes
You can format your clinical notes directly in the sidebar editor whilst creating your note. Formatting helps keep notes clear and structured.
Using the slash ( / ) menu
While typing in your note, type a forward slash '/'.
This opens the formatting menu.
From here, you can select options such as:
Bold text
Italic text
Numbered lists
Bullet points
Simply choose the option you need and continue typing.
You can also use the slash menu '/' to add add templates. Simply type slash and then the shortcut name for your template - e.g '/ex01' and click enter to add your template directly into the editor.
Using the highlight toolbar
You can also format text after writing it.
Highlight the text you want to change
A small editing toolbar will appear
Select the formatting option you’d like to apply
For example:
Bold for headings
Italic for emphasis
Numbered or bullet lists for structured notes
Undo and redo
If you make a mistake, you can use the buttons across the top of the editor to:
Undo edits
Redo edits
Your note automatically saves a new draft every 10 seconds, so you don’t need to manually save your changes.
How to make amendments to locked clinical notes
If you have already signed and locked your clinical note before noticing an error or a missing piece of information from your transcript you can use the tool to add amendments easily to your saved notes.
Open the clinical note sidebar for the signed and locked appointment note in question.
Click on the 'Add amendment' button at the bottom of the clinical sidebar.
Add any missing information into the amendment box and select 'Add'
This will save your amendment to the top of the note with a date, time and user stamp for clear visibility.
💡 Top Tip - Missed something else? No need to worry as you can add as many amendments as needed to each note.
How to create and edit clinical note templates
🚨 Important - The note editor located in Settings → Templates → Notes is now a legacy editor and should not be used to keep your clinical note templates up to date.
Navigate to a test patient to avoid making edits to existing patient notes.
Open a treatment plan and add an appointment
Open the note sidebar using the 'Clinical sidebar' button and clicking on the 'Notes' tab.
Or by using the 'Create note' button against the appointment.
Click '+Add template' or type '/' and select 'View all templates'
How to create a new template
After navigating to your template editor click on '+New template'
Give your template a title, and use the formatting options to create the body of your template.
For the best results use our top tips guide for creating templates.
Click 'Save' to finalise your changes.
After saving, set a shortcut for your template in the bottom right - this means in the future you can use the '/' slash menu to quickly add your template to your note editor.
The shortcut name must contain only lowercase letters and numbers and be more than 3 digits long.
How to clone an existing note template?
If you have an existing practice template that you use often but want to make a few edits to make it more suitable for your unique needs then you do this by:
Navigate to the note template editor.
Click onto the practice template in question on the left.
Clicking the blue 'Make a copy' button along the top of the template.
Make any edits needed and click 'Save'
This will then create a personal template for you to use.
How to edit an existing note template?
To edit your own personal templates:
Navigate to the note template editor.
Click on template you wish to edit
Type any edits you wish to make to the templates in the editor
Click 'Save' to confirm any edits.
These will then be applied to the note template going forward.