Editing Procedures
Procedures are usually entered in the Chart module using the Enter Treatment tab. To edit a procedure, double click it in the Account module, the Treatment Plan module, or the Chart module.
To edit, delete, or set procedures complete, the logged on user must have the correct security Permissions. Once procedures have been attached to a Claim, a note will show at the bottom of the Procedure Info window warning you that certain fields should not be changed. To make changes anyways, click Edit Anyway.
Dates:
- Date Entry: The day the procedure was entered; it cannot be changed.
- Date TP: The day the procedure was added to the treatment plan.
- Date: Date of the procedure. Enter start and end times, or click Now to add the current time. The Final field will automatically calculate the total minutes.
Procedure/Description: Click Change to select a different procedure code from the Procedure Code List. This will also update the Amount field. If the new code's treatment area is different, you will not be allowed to change it due to a 'treatment area mismatch'. For example. you cannot change a filling procedure to a prophy procedure, because the treatment area for a filling is Tooth and for a prophy is Mouth. Once you attach a Claim to an incorrect procedure, it is more complex. See Fixing Incorrect Procedures on an Insurance Claim.
For guidelines on entering procedures that involve multiple appointments, see Lab Cases.
Tooth/Surface: Options for tooth number and surfaces are different depending on the Procedure Code's Treatment Area.
- Tooth: A single tooth number. This is required if treatment area is set to tooth.
- Surfaces: B/F, V, M, O/I, D, L. Enter or click a button to select. Click again to clear. This is required if treatment area is set to surface.
- Quadrant: UR = upper right, UL = upper left, LR = lower right, LL = lower left
- Sextant: 1 - 6 in United States. 03 - 08 in Canada.
- Arch: U = upper, L = lower
- Tooth Range: 1 – 32. Click and drag to select a range of teeth.
To use international tooth numbers, or for information on valid tooth numbers or supernumerary teeth, see Chart Module Setup, Tooth Nomenclature.
Amount: The billable fee of the procedure based on the assigned Fee Schedule. Enter default fees in the Procedure Code list. The fee only shows if the logged on user has the Show Procedure Fee Permission.
Hide Graphics: Check this box if you do not want to show this procedure on the Graphical Tooth Chart.
Provider: The Provider associated with the procedure. Usually the patient's primary is already selected or the provider is assigned when making the appointment.
Clinic: Only visible if Clinics is turned on in Show Features.
Diagnosis: You can select one diagnosis per procedure. If a procedure requires more than one diagnosis (for instance: cracked tooth, IP, Apical perio) add them as notes. Diagnoses do not affect the graphical tooth chart. Customize options in Definitions, Diagnosis. To see diagnoses separately from the proposed treatment, see the comments regarding the Condition (Cn) Status.
Priority: Used to prioritize treatment in the Treatment Plan module. Options can be customized in Definitions, Treat' Plan Priorities.
Prosthesis Replacement: Only visible if the Procedure Code has been setup as “Is Prothesis.” This information is required before a Claim can be sent electronically.
E-claim Note: A place for short notes that pertain to this procedure. Limited to 80 characters. It should be used rarely and is only sent in E-Claims; it will not print on paper claims. The note is procedure level, not a claim level. To enter a Claim Note, see Claims.
Procedure Status: The procedure status can be one of the following:
- Treatment Planned (TP): For work that is recommended, but not complete yet.
- Complete (C): The work is done and will show in the patient's Account.
- Existing-Current Prov (EC): Procedure was done in your practice before you started using Open Dental.
- Existing-Other Prov (EO): Procedure was done by another provider, either before the patient came to your practice, or because they were referred out for treatment.
- Referred Out (R): Procedure the patient needs, but that will be done at another office. Once the work has been completed, you can change the status of the procedure to EO.
- Condition (Cn) - Chart caries and other conditions as a separate step in order to see them on the graphical tooth chart. Most offices will not use this status. To use this status, you must also add dummy Procedure Codes that represent the conditions you are trying to show. The mouth area and paint type of each dummy code must be carefully set.
The procedure status determines the color used on the Graphical Tooth Chart.
Set Complete: Assign the status of complete, insert default Procedure Notes, change the Date Entry and Date to today's date, and close the window.
Referral: Click […] to refer this procedure to a Referral source. Referrals out can be Tracked individually.
Notes: This Text Box is for Procedure Notes and is usually empty until the procedure status is Set Complete. Once set complete, default procedure notes are automatically copied and staff can make changes to the notes as needed. If a note contains quotes “”, then information must be filled in between the quotes, or the note is considered Incomplete. Click AutoNote to add a presetup auto note to the notes area.
Viewing Old, Signed Procedures: In version 13.1, the Notes box was enhanced. As a result, if you open a procedure created before the update, the note may be be changed. Sometimes hidden characters are added or removed. Make sure to click Cancel instead of OK when exiting the window so the note is not permanently changed. Otherwise, the hidden characters will be saved, and the change to the note will invalidate any digital signature.
Signature: Add a Digital Signature. Signatures are tied to the note, so if the note changes, the signature will be invalidated.
Tabs: See Financial Tab, Medical Tab, or Misc Tab.
Delete: Hide this procedure. The procedure will appear to be deleted, but will actually be hidden. Be very careful to make sure you don't lose any clinical information and that the Account remains accurate. Deleted procedures can only be viewed in Audit mode on the Show tab.
