Clinical notes and medical history

Write, complete and sign clinical notes, and keep the patient's conditions, medications, allergies and alerts as an append-only history.

Both live on the patient page of the PMS workspace, beside the chart.

Clinical notes

The Notes tab of the clinical record lists every note as a timeline, newest first, with the date on the left and the note's kind, author, time and state on its first line. A long note shows its first three lines; click the text to open it out. An addendum sits indented under the note it corrects, never on its own. The filters above the list narrow it to a state (All · Draft · Completed · Signed), an author, or a word in the text; a matching addendum keeps its parent on screen, so a draft addendum on a signed note still shows under Draft. Each row's actions are buttons named for what they do — Edit, Complete, Sign, Add addendum — shown only to the member who may take them.

New note sits above the list, and in the record's header on every tab: there it opens Notes with a new note ready to write. The patient's pinned, non-clinical note is not on this tab: it is the Note in the record's header.

A note has three states and never goes backwards:

State	Who can change it	How
Draft	Its author	Edit the body freely
Completed	Nobody edits the body	Sign it, or write an addendum
Signed	Nobody	Addenda only

Click New note and choose the kind (clinical, procedure or progress) and the location.

Write the note. The toolbar formats it — bold, italic, underline, headings, bullet and numbered lists, links, undo and redo. Insert template in the toolbar lists the practice's note templates by category and adds the one you pick where the cursor is, so you can combine several in one note. The practice starts with eight structured templates — new patient examination, routine examination, hygiene visit, restorative treatment, extraction, root canal treatment, emergency visit and review — under Settings → Note templates. A nurse chooses the supervising dentist; the note is recorded under the nurse's name with the dentist's beside it.

Click Save draft. Come back to Edit as often as needed. A draft saves as you type; if it was saved elsewhere in the meantime, the editor keeps your text and shows theirs so you can Keep mine or Use theirs, and closing with unsaved text asks you to Save or Discard.

Click Complete when the note is finished. The body is sealed from that moment. Smileline completes exactly the version you last saw: if someone saved a newer version in the meantime, it is not sealed, and you see the newer text first.

A dentist, hygienist or therapist clicks Sign and confirms their password. The note is now immutable evidence.

Templates with questions

A note template can come with questions (set under Settings → Note templates, Questions). When you insert one, its questions appear above the text: yes/no, a choice, a number, a date or a few words. Some appear only after an earlier answer — "Dose" once "Local anaesthetic" is Yes. A draft saves its answers as you go, and a note of answers alone, with no text, saves too.

Complete needs every required question that is showing; a hidden one is never required.
A note has the questions of one template. Inserting another template that has questions asks before it Replaces them, which clears the answers.
The note keeps the exact questions it was answered against: editing the template later never changes a written note. If the template was edited while you were writing, Smileline reloads its questions and asks you to check your answers before it saves.
The answers are sealed with the note when it is completed, and signing covers them. The timeline shows each question with its answer, or Not answered, under the note's text, and its search finds them.
Correct carries the questions and answers into the new draft, even if the template was archived since.
The phone app shows the answers and lets you edit the text of such a draft; you complete it on the web, where its questions are.

Phrases

A short template is a phrase, such as "Patient tolerated the procedure well". Type / in the note, start typing its name, and press Enter (or click it) to insert it where the / was. The arrow keys move through the list and Escape closes it.

To correct a completed or signed note, click Add addendum: a new note that refers to the original. The original never changes. An addendum, like a correction, belongs to the same appointment and treatment as the note it refers to.

If the connection drops while a note is being saved, saving again files it once. Smileline recognises the repeat, so the same note never appears twice.

Entered in error

A note that should never have been written — on the wrong patient, say — is marked Entered in error with a reason. It stays on the record as evidence but leaves the timeline, with who marked it, when and why; Show entered in error lists such notes again.

A draft is marked by its author.
A completed or signed note is marked by a dentist, hygienist or therapist, who confirms their password.

Correct marks the note entered in error and opens a new draft filled with its text, linked to the note it replaces. Edit it, then complete and sign it as usual. Use Add addendum instead when the note was right and something needs adding.

Dentists, hygienists and therapists author and sign; a nurse authors under supervision and never signs. Front-desk roles read notes and cannot write them.

Notes drafted from a voice note

Where voice notes are switched on, a recording's draft can start a note. In the draft's panel beside the editor, click Use draft: its paragraphs go in at the cursor, and its answers fill only the questions you haven't answered, on a note with the same template's questions. Nothing is saved until you save the note, and only the clinician who made the recording can use its draft.

The note is then labelled Drafted from a voice note. You edit, complete and sign it exactly as any other note: Smileline never completes or signs it for you. Play the recording from the note to check what was said. Completing the note keeps the recording with the patient's clinical record.

Notes on a treatment

A note written on a treatment from its treatment plan is a procedure note tied to that treatment. It is listed here like any other note, and under the treatment in the plan, and it follows the same draft, complete and sign steps. An addendum to it stays on the same treatment.

When the treatment's code has a Note template (set in the clinical catalogue), the note box offers it: Suggested: Extraction with Insert and Dismiss. Insert adds a line naming the treatment and its site (for example "Extraction · UR6"), then the template's text, and its questions if it has any. Nothing is ever written for you.

A code marked Requires a clinical note asks for the note when you Complete the treatment on the web, if it has none yet: the dialog has a Clinical note box filled with the treatment's line and its suggested template. The note is saved as a draft first, then the treatment is completed; if the completion fails, Retry completes it without saving the note again. Clear the box to complete without a note.

Medical history

Conditions, medications and allergies are facts that are only ever added to. Correct writes a new row and archives the old one; Archive retires a fact that no longer applies. Archived rows stay visible, struck through, so the history reads as it happened, and each records who archived it and, when given, why — "Replaced" for one a correction archived. A fact marked From form came from a patient's own form after a clinician reviewed it.

A fact can carry a clinical code, for example one imported from another system. A correction that only changes its details, such as a dose or a reaction, keeps the code. If you change a coded fact's name, Smileline asks whether the code still applies, Keep code or Unlink code, so a renamed drug or substance never keeps a code that now names something else.

Front-desk staff can record what a patient tells them at the desk; the clinician sees it on the next visit.

Alerts

Alerts are the pills everyone sees in the record's header: an allergy, an infection-control note, a warning. Clinicians read their words, the desk their kind. Raise one with Raise alert and a severity; critical alerts pop up when the patient's Chart or Perio is opened by a dentist, hygienist or nurse. Archive an alert when it no longer applies. An alert marked as coming from an unreviewed form is provisional until a clinician reviews the form.

Clinical notes and medical history

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