Clinical Documentation Guide
Four Methods. One Goal: Go Home on Time.
Overview
NoteIQ gives you five methods to document: Blocks, Templates, Transcription, Phrases, and Elements.
The fastest method for most practices is Click-n-Go: your dental assistant clicks pre-built blocks during the visit, the note assembles itself, and you review and sign in seconds. No dictation learning curve. No typing after hours. Your clinical style—captured in blocks you design once—flows through your team every day.
But Click-n-Go isn't the only way. Complete Procedure Templates work beautifully for predictable procedures like prophys, simple extractions, or crown deliveries. And Voice Dictation remains available when you want to narrate complex findings in your own words.
The key insight: you design the system once, your team executes it daily.
The Five Documentation Methods
1. Click-n-Go with Blocks
What it is:
Blocks are reusable building pieces—like a flexible checklist for each part of the dental visit. Click a block, and its content inserts into your note. Mix and match blocks to document exactly what happened.
How it works:
- DA seats patient → clicks "Patient Seating" block
- During/after procedure → DA clicks relevant blocks (anesthesia, isolation, restoration, etc.)
- Dentist reviews → approves or edits → signs
When it shines:
- Longer visits with multiple procedures
- Varied or unpredictable procedures
- When you want flexibility without starting from scratch
- When your DA handles most documentation
Example workflow:
Morning hygiene patient with unexpected finding:
DA clicks: Hygiene Seating Block
DA clicks: Prophy Block
DA clicks: BWX Block
Dentist examines, finds crack → DA clicks: Clinical Finding - Tooth Fracture
Dentist recommends crown → DA clicks: Treatment Recommendation Block
DA clicks: Patient Education Block
Result: Note is 90% complete. Dentist reviews, adds one sentence, signs. Total dentist time: 30 seconds.
Why blocks are gold:
Blocks don't lock you in. Unlike rigid templates, you choose which blocks to use based on what ACTUALLY happened—not what you planned. They're organized by visit phase (seating, exam, procedures, dismissal) so your DA works through them like a checklist.
2. Complete Procedure Templates
What it is:
A procedure template is a pre-built, complete workflow for a specific procedure. Select the template, fill in the variables (tooth number, shade, etc.), and the entire note generates.
How it works:
- Select procedure template (e.g., "Crown Prep - PFM")
- Fill in blanks: tooth #, shade, margin type, etc.
- Template generates complete S-O-A-P note
- Review, edit if needed, sign
When it shines:
- Predictable, routine procedures
- High-volume procedures (prophys, simple extractions, crown deliveries)
- Hygiene visits (most are similar)
- When consistency matters more than flexibility
Example workflow:
Crown delivery appointment:
Select template: Crown Delivery - PFM
Fill in: Tooth #14, Shade A2, Ivoclar cement
Template generates complete SOAP note...
Result: Review, sign. Done in 15 seconds.
3. Voice Dictation and Typing
What it is:
Speak or type your notes in natural language. NoteIQ's AI, trained on 8,000+ dental terms, transcribes and formats your words into proper clinical documentation.
When it shines:
- Complex clinical findings that need narrative description
- Unusual cases where no block or template fits
- When you prefer to document in your own words
- Dictating while the finding is fresh in your mind
4. Phrases
What it is:
Individual clinical phrases you can insert with one click. The finest level of granularity for quick additions and fine-tuning.
When it shines:
- Quick additions to existing documentation
- Specific findings you document frequently
- Standard statements (consent obtained, patient tolerated well)
- Building blocks for creating your own blocks/templates
How it works:
Writing in the Objective section...
Need to add: "Caries detected on mesial surface"
Click phrase from library → Inserted.
Mark frequently-used phrases as favorites for instant access.
5. Elements
What it is:
Elements are the specific clinical items used during procedures—anesthetics, materials, instruments, sutures, and medications. With 2,600+ procedural elements organized into 16 categories, you can document exactly what was used with precision.
Categories include:
When it shines:
- Documenting specific materials and products used
- Recording anesthetic type, amount, and technique
- Tracking instruments and equipment
- Building detailed, defensible clinical records
Example usage:
Anesthetic: Lidocaine 2% with 1:100,000 epi, 1.7mL, 27G short, infiltration
Isolation: Rubber dam, clamp #14
Material: 3M Filtek Supreme, shade A2
Cement: RelyX Ultimate
The "This Patient" Button
Patient Prep Mode
What it is:
Like setting up a clinical tray before a procedure, Patient Prep lets you collect all the templates, blocks, phrases, and elements you'll need for a specific patient's visit—before they even sit in the chair.
How it works:
- Click "This Patient" button in the SOAP Editor
- Browse and collect items from all four categories
- Items appear in your Clinical Tray
- Click items from your tray to insert during documentation
Perfect for:
- Morning huddle: Prep trays for the day's procedures
- Complex cases: Gather everything you might need
- Training new staff: Show them what to document
- Consistent workflows: Same prep for same procedures
When to Use What
| Situation | Best Method | Why |
|---|---|---|
| Routine prophy | Template | Same every time |
| Crown prep | Template or Blocks | Predictable but may vary |
| Multi-procedure visit | Blocks | Mix and match what happened |
| Unusual finding | Voice + Blocks | Narrate the unusual, block the routine |
| Emergency exam | Blocks | Flexible, fast |
| New patient comprehensive | Blocks | Too varied for one template |
| Quick addition to any note | Phrases | Fine-tune with standard statements |
The Workflow: Design, Execute, Review
NoteIQ is built on a simple insight: the dentist's clinical expertise should be captured once and executed infinitely.
Dentist Designs
(Once)
- • Creates/customizes blocks
- • Builds procedure templates
- • Encodes clinical style
Team Executes
(Daily)
- • DA clicks blocks during visits
- • Hygienist uses templates
- • Notes assemble from your system
Dentist Reviews
(Seconds)
- • Quick review of completed note
- • Edit if needed
- • Sign and done
Why This Works:
Getting Started
You Don't Start from Scratch
NoteIQ includes a comprehensive pre-built library:
- 54 procedure blocks organized by procedure type and visit phase
- 111 procedure templates for common dental procedures
- 2,600+ clinical phrases and elements for detailed documentation
- 8,000+ dental terms in our AI vocabulary
Start using them immediately. Customize only what you need to match your style.
Summary
Flexible building pieces. Best for varied visits.
Complete workflows. Best for predictable procedures.
Natural language. Best for complex narratives.
Quick additions. Best for fine-tuning.
Clinical items. Best for materials & supplies.
Design once. Execute daily. Go home on time.
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