How to Write Clinical Notes
Accurate clinical documentation is essential for continuity of care, legal protection, and insurance claims. MyDentalPractice provides structured note-taking tools for every patient visit.
Creating a Clinical Note
Open the patient recordNavigate to the Notes tabClick + New Clinical NoteThe note form opens with today's date and your name pre-filledNote Structure
Each clinical note follows a structured format:
Chief Complaint
Record the patient's primary reason for visiting in their own words:
"Pain in lower right jaw for 3 days""Routine checkup and cleaning""Crown fell off while eating"Examination Findings
Document your clinical observations:
Visual findings — Caries, swelling, discoloration, soft tissue abnormalitiesProbing depths — Record periodontal pocket depths if applicableMobility — Note any tooth mobility gradesVitality tests — Results of cold test, electric pulp test, or percussionDiagnosis
Select from standardized diagnoses or enter a custom diagnosis:
Reversible pulpitisIrreversible pulpitisPeriodontal abscessDental caries (specify tooth and surfaces)GingivitisTreatment Performed
Document the procedure in detail:
Treatment type (selected from your treatment catalog)Tooth number and surfaces involvedMaterials used (e.g., composite shade A2, local anesthetic type and dosage)Duration of the procedureAny complications or unusual findingsPost-Operative Instructions
Record instructions given to the patient:
Medications prescribedDietary restrictionsFollow-up timelineWarning signs to watch forTemplates
Save time with note templates for common procedures:
Go to Settings → Templates → Clinical NotesClick + Create TemplatePre-fill the sections for common scenarios (e.g., "Extraction Note", "Scaling and Polishing Note")When creating a new note, click Use Template to start from a saved templateSigning Notes
Clinical notes must be signed by the treating dentist:
After completing the note, click Sign NoteEnter your password or use biometric authenticationThe note is locked and timestampedSigned notes cannot be edited. If corrections are needed, create an addendum that references the original note.
Viewing Note History
All clinical notes for a patient are displayed in reverse chronological order on the Notes tab. Use the search and filter options to find specific notes by date, dentist, or treatment type.
For dental charting, see How to Use Dental Charting. For patient medical history, see Medical History.