Creating a Dental Medical Record

A dental (odonto-stomatology) medical record goes through four stages: the patient is received, the doctor charts the teeth on the dental chart during the exam, the doctor concludes and signs, and the record is printed. This page links those stages in the order you click through them, and shows how the chart the doctor fills in appears on the printout.

The whole workflow in one table

Step	Where · what for
1. Department	The visit belongs to the Dentistry department (the appointment's or the record's department). The doctor is assigned to Dentistry in HR › Adding a Staff Member — done once per doctor.
2. Reception	Medical Records › Reception - Examination — receive the patient, click Check-in, then click the name to open the examination screen.
3. Exam and charting	Exam tab — record vitals and the clinical exam, chart the Dental Chart, the periodontal exam and occlusion. Click Save vitals.
4. Conclusion	Conclusion › Diagnosis & Sign tab — diagnosis, ICD-10 code, click Save conclusion. This is when the medical record is created.
5. Sign	Click Sign with CA — the record is completed and locked.
6. Print	Medical Records › Medical Records List — click Print medical record on the patient's row.

Step 1 — The visit belongs to Dentistry

The examination screen follows the department of the visit, not which doctor opens it:

1. The visit already has a medical record → the record's department.
2. No record yet → the appointment's department (an appointment booked from a dental treatment session carries Dentistry automatically).
3. Neither has a department → the default department of the doctor who is signed in.

When the visit belongs to Dentistry, the Exam tab gains a Dental Chart block and the printout uses the odonto-stomatology form. A visit of another department shows that department's examination. So a doctor working in both dentistry and dermatology always sees the right screen for the visit they open.

The doctor needs to be assigned to Dentistry: open the doctor's profile in HR and tick Dentistry in Search and pick departments. Doctors in several departments tick them all and set the one they work in most as the default — see Adding a Staff Member. Treatment sessions recorded after the exam also follow the service's department — see Record a Treatment.

Step 2 — Receive the patient and open the examination screen

In Reception - Examination, booked patients are already on the list; walk-ins are taken in quickly by phone number or name. When the patient is in front of you, click Check-in. The doctor then clicks the patient's name to open the examination screen for that visit. Details: Reception - Examination.

Step 3 — Chart the teeth

On the Exam tab, record vitals and the clinical exam as in any department. Scroll down to the Dental Chart block — Odontogram, periodontal, occlusion (Dental).

Pick a condition, then click the tooth

Charting always takes two beats: pick the condition first, then click the tooth.

1. Click a condition in the row of coloured buttons at the top, for example Caries. The selected button turns solid.
2. Click a tooth surface on the chart. That surface takes the condition's colour.
3. Keep clicking other teeth with the same condition. To switch conditions, click another button.

Each tooth is drawn as 5 cells: the centre is the occlusal surface, and the four around it are mesial, distal, buccal and lingual. Teeth use the two-digit international numbering — the first digit is the quadrant, the second is the position counted from the midline. For example, 36 is the lower-left first molar.

Surface conditions and whole-tooth conditions

There are two kinds of condition, and the software handles each correctly on its own:

Kind	Clicking one surface…
Per surface — Caries, Fracture, Abrasion, Cervical erosion, Filling, Inlay, Onlay, Calculus, Gingivitis, Gum recession, Other	Colours only the surface you clicked. A tooth with occlusal and mesial caries: click those two surfaces.
Whole tooth — Missing, Implant, Crown, Bridge, Post & core, Root canal, Need extraction, Braces, Pulpitis, Pulp necrosis, Abscess, Periodontitis, Impacted tooth, Tooth mobility, Malocclusion, Tooth discoloration	Colours all 5 surfaces at once — click any surface. Missing also draws a red X over the tooth.

One surface can hold several conditions — for example both Filling and Caries (recurrent decay). On the chart, the surface shows the colour of the condition recorded first; the printout lists both (see Step 6).

Removing a condition

• Remove one condition from one surface: pick that same condition and click the surface again — it goes back to white.
• Clear a whole tooth: pick Remove/Restore and click the tooth — every condition on it is cleared.
• Clear selection (right end of the button row) only deselects the current condition button; nothing on the chart is removed.

Quick select for many teeth

The Quick select row applies the selected condition to a whole group in one click: 16 teeth (incisors and canines), 20 teeth (excluding wisdom teeth), Upper jaw, Lower jaw, All. These buttons become clickable once a condition is picked. Example: full-mouth scaling → pick Calculus → click All.

Permanent and milk teeth

The toggle on the right switches the chart between Permanent tooth and Milk tooth. For children, switch to Milk tooth before charting.

Periodontal, occlusion and soft tissue

Below the chart are the specialist sections: Periodontal Examination (PI and GI scores, pocket depth, tooth mobility), Oral Hygiene (OHI-S), Occlusion Examination (overbite, overjet, open bite, crossbite, Angle class on each side) and Soft Tissue Examination. Fill in what this case needs and leave the rest blank.

Save

Click Save vitals on the bar at the top of the tab. This one button saves everything: vitals, the clinical exam, the dental chart and the periodontal exam.

Editing the chart after the record exists

Once the record exists (you clicked Save conclusion in step 4) and is not yet signed, every chart edit only needs Save vitals — the record and its printout follow the new chart, with no need to go back to the Conclusion tab and save again.

Step 4 — Conclude and create the record

Go to the Conclusion tab, sub-tab Diagnosis & Sign:

• Primary diagnosis and Primary ICD-10 — required before signing. For example, caries takes a code from group K02, pulpitis from group K04, periodontitis from group K05.
• Secondary diagnosis, Secondary ICD-10 — when the patient has other conditions too.
• Fill in the condition, treatment plan or follow-up plan.

Click Save conclusion. The first save creates the medical record for the visit and copies the step 3 chart into it.

Prescriptions and treatment sessions live in the neighbouring Prescription and Treatment sub-tabs.

Step 5 — Sign the record

Review, then click Sign with CA and confirm in the Confirm signing record dialog. Once signed, the record is completed and locked: the chart and diagnosis can no longer be edited directly.

Doctors can also sign from the Medical Records List — click Sign medical record on the row, review the exact printout, then sign. Details: Medical Records List.

After signing

A signed record cannot be edited directly. To change it, use Amend — the software keeps the previous version and records the reason and who made the change.

Step 6 — Print the record

Open Medical Records › Medical Records List, find the patient and click the printer button Print medical record in the row's button group. Dentistry records print on the Outpatient Medical Record — Odonto-Stomatology form. You can print before signing too, to review it.

The dental chart sits under IV. Physical examination › 3. Diagram of lesions on admission, in three parts:

Part	What it shows
Dental chart	The permanent dentition (plus the milk-teeth row), coloured exactly as the doctor charted. Missing teeth carry a red X.
Color legend	What each colour on the chart means. It lists only the conditions present in this record, so it stays short and matches the picture.
Dental findings	A text table, one row per tooth: the tooth number, each condition with its colour swatch, and the location — Whole tooth or the surface names (Occlusal, Mesial…).

The Dental findings table stays readable in black and white or on a photocopy: anyone can see which tooth has what, on which surface, without matching colours. When a surface has two conditions, the table lists both, even though the picture shows only one colour.

Example: the doctor charts tooth 36 Caries on the occlusal and mesial surfaces, and tooth 46 Missing. The printed table reads:

Tooth	Condition · Location
36	Caries — Mesial, Occlusal
46	Missing — Whole tooth

Frequently asked questions

The Exam tab has no Dental Chart. This visit does not belong to Dentistry — the appointment or record carries another department, or neither has one and the doctor's default department is not Dentistry. See Step 1.

I edited the teeth but the printout has not changed. Check that you clicked Save vitals after editing, and that the record exists (Save conclusion clicked at least once). A signed record changes only through Amend.

Clicking a tooth does nothing. No condition is picked — the hint Select a status first appears next to the Quick select row. Pick a condition, then click the tooth again. If the whole chart is faded and unclickable, the record is locked.

Related

• Adding a Staff Member — assign departments and the doctor's default department.
• Reception - Examination — the day's examination queue.
• Medical Records List — sign, print, close treatment episodes.
• Treatment Episode Timeline — multi-session treatment.