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Notes, prescriptions, orders and attachments

Write the visit notes, prescribe medicine, order lab or imaging work, and attach photos or documents, all from the encounter.

Time: about 5 minutes · You'll need: an open encounter for the patient.

Before you start

  • Open the patient's encounter. See Start an encounter.
  • Everything on this page is in the row of views under the chart: Chart list, Records, Prescription, Orders, Attachments and Orthodontics. Scroll down below the chart to see it.
  • To have your licence number printed on prescriptions, add it to your profile first: Settings › Profile. See Settings basics.

Write the visit notes

1. Open Records

Tap Records in the row of views. The notes are laid out in four columns:

  • Subjective: what the patient tells you (Allergies, Chief complaint, History of complaint)
  • Objective: what you find (Vitals, Soft-tissue exam)
  • Assessment: the conditions you've recorded on the chart
  • Plan: what happens next (Post-op instructions)

An empty column says Nothing recorded. (Assessment says No active conditions on the chart.) and shows + buttons for what you can add.

You should see: the four columns, with + Chief complaint under Subjective.

The Records view: Subjective, Objective, Assessment and Plan columns, each with add buttons such as + Chief complaint and + Vitals

2. Add the chief complaint

Tap + Chief complaint, type the patient's Main concern, then tap Save. Other notes work the same way.

You should see: Add chief complaint with a Main concern box.

The Add chief complaint form with the main concern typed in: Pain on a lower left tooth when chewing, for a week

A message says Added chief complaint, and the note appears as a card under Subjective. Tap the card to read or change it.

The Records view with a Chief complaint card under Subjective and the message Added chief complaint

3. Record allergies

Always check allergies before you treat or prescribe.

  1. Under Subjective, tap + Allergies.
  2. If the patient has none, switch on No known allergies.
  3. Otherwise, under Allergen, type the start of the name and pick it from the list, for example Penicillin.
  4. Choose the Severity: Mild, Moderate or Severe.
  5. Add First observed and Additional information if you know them.
  6. Tap Save.

You should see: Add allergies with the allergen and severity filled in. Afterwards, an allergy card appears under Subjective; a severe allergy is marked Severe allergy in red.

The Add allergies form: No known allergies switch, Allergen Penicillin, Severity Severe, First observed, and Save

Allergies recorded at an earlier visit are carried into every new encounter. Tap the card to read them: the reader says where they came from, for example From Oct 30, 2026 encounter, and they can't be edited from this visit.

4. Record vitals

Under Objective, tap + Vitals. Fill in what you measured: Systolic and Diastolic blood pressure, Temperature, Height and Weight. Leave the rest empty. Tap Save.

You should see: a Vitals card under Objective, for example 120/80 BP.

The Add vitals form with Systolic 120 and Diastolic 80 mmHg, and empty Temperature, Height and Weight boxes

5. Read or change a note

Tap any card to read it in full: who recorded it, when, and the details. While the visit is still open, tap Edit to change it, then Save.

You should see: the note with Edit at the top right.

The Chief complaint opened from its card: the date and time, the text, Details, Source, Recorded by Ana Santos, and an Edit button

After the visit has ended

The button reads Amend… instead of Edit. Make your change and tap Continue. Dentalemon then asks why: choose Correction, Late entry, Clinical update or Other, add a note if you want, and tap Amend. The reason is kept in the record's history. Tap Keep to go back without saving.

The Amend record step: Choose a reason. It is kept in the Record Log. Correction, Late entry (chosen), Clinical update and Other, a Note box, and Keep and Amend buttons

Prescribe medicine

6. Find the medicine

Tap Prescription in the row of views, then Add prescription.

Type part of the name in Search name, brand or strength, for example amox, then tap the medicine and strength you want.

If the patient is allergic

The patient's allergies show in red under their name, for example Penicillin · Severe, and every matching medicine in the list has a red warning sign. When you tap one, Dentalemon warns you before adding it, for example Penicillin allergy on record · Severe. Tap Keep current to go back without adding the medicine, or Choose medicine to add it anyway. Record allergies first (step 3) so this check can work.

Add prescription for a patient with a severe penicillin allergy: Penicillin · Severe in red under the patient's name, and a red warning sign next to each amoxicillin in the search results

You should see: a list of matching medicines under Medicines.

The Add prescription form with amox typed in the search box and a list of amoxicillin strengths and forms

7. Fill in the directions

The Medicine page opens with the name, strength and form filled in. Under Directions, fill in:

  • Take: the amount and unit, for example 1 capsule
  • Route: for example By mouth
  • How often: start typing and pick a suggestion, for example 3 times a day
  • For how long: for example 7 days

Under Quantity and refills, enter the Quantity to dispense.

Tap Prescription at the top left to go back.

You should see: the medicine details and the Directions you entered.

The Medicine page: Amoxicillin 500 mg capsule, Take 1 capsule, Route By mouth, How often 3 times a day

8. Check and save the prescription

The prescription now lists the medicine with its directions in plain words. To add another medicine, search again.

Under the medicines:

  • Destination: where the patient gets the medicine, Patient-arranged unless you change it. Change in Settings opens Settings › Partners in front of the prescription, where your clinic's referral partners are kept.
  • Add professional credentials (under your name) opens Settings › Profile, where you add your licence numbers.
  • Remove all medicines clears the list and starts again.

Tap Save.

You should see: 1. Amoxicillin 500 mg capsule… with 1 capsule by mouth 3 times a day for 7 days under it.

The Add prescription form showing the medicine and its directions, Include impression, Destination Patient-arranged with Change in Settings, Remove all medicines, and Save

9. Print it

The prescription appears in the Prescription view, laid out as it will print: your clinic, the patient, the Rx with Sig: and Disp., and your name and licence numbers.

You should see: the prescription with Print and Add prescription above it.

The saved prescription: Lemon Tree Dental, the patient, Rx Amoxicillin 500 mg capsule with Sig and Disp. 21, signed by Ana Santos, Prescriber, with PRC Lic. No. and PTR No. lines

Tap Print. Print prescription opens with a preview. Choose the Paper size (Half letter, A5 or Letter; Dentalemon remembers your choice), then tap Print to print it or save it as a PDF. A draft prescription is issued when you print it: the sheet says Printing issues this prescription.

If your licence number isn't set, the sheet says Your licence number isn't set. Tap Add in Settings to add it, or print with a blank line to write on.

You should see: Print prescription with the paper preview, Paper, Cancel and Print.

Print prescription: the prescription on paper, Your licence number isn't set with Add in Settings, Paper Half letter, the note Printing issues this prescription, and Cancel and Print

Order lab or imaging work

10. Add an order

Tap Orders in the row of views, then Add order, and choose Lab order or Imaging order.

You should see: a small menu with Lab order and Imaging order.

The Orders view with the Add order menu open, showing Lab order and Imaging order

11. Choose the tests

  1. Pick the Kind, for example Laboratory or dental lab.
  2. Choose Individual tests or Package.
  3. Tick the tests you want, or use Search catalogue. The list includes dental lab work (crowns, dentures, night guards) and blood tests. If a test isn't listed, type its name and tap Use "…". Work from the patient's treatment plan is offered under From the treatment plan.
  4. Under ICD-10, search by code or name to add the diagnosis if you need to.
  5. Under Clinical reason, say why you're ordering it.
  6. Check the Destination: In-house, Referral partner or Patient-arranged.
  7. Tap Save.

You should see: a tick beside each test you chose, and the chosen tests listed under the catalogue, each with ✕ to remove it. The list stays where it is while you tick, and your search stays in the box.

The Add lab order form: Kind Laboratory or dental lab, Individual tests, Complete blood count selected, and the catalogue list

An Imaging order works the same way. Its Kind is Dental imaging, and the list has X-rays such as Periapical radiograph, Bitewing radiograph, Panoramic radiograph and Cone-beam CT.

The Add imaging order form: Kind Dental imaging, Periapical radiograph selected, and other radiographs in the catalogue list

12. Check the order sheet

The Orders view shows every order for this visit on one order sheet, grouped by kind (Laboratory, Imaging, Prescriptions), with each one's Destination and Status.

New orders start as Draft. Tap a line to see its details. The + Lab order and + Imaging order links under the list add a kind of order the sheet doesn't have yet.

You should see: your order listed with the status Draft.

The order sheet: Laboratory Complete blood count In-house Draft, and Prescriptions Amoxicillin Patient-arranged Draft

13. Send orders from the Orders page

Draft orders are sent when you finish the visit (see Finish the visit). To send one sooner, or to follow up on orders across the clinic, tap Orders in the sidebar.

Clinic orders lists every order in your clinic. By default it shows Open orders (Draft and Requested). Use the Status, Type and Date filters, or Search orders… by patient name. List and Table switch the layout. A row's ⋮ menu has View encounter and Record logs.

Clinic orders: a table of open orders from all patients with Type, Order, Status and Date ordered

To send an order, tick it, then tap Send. Discontinue… cancels it (you'll be asked why).

You should see: 1 order selected with Send and Discontinue….

Clinic orders filtered to Draft for one patient, with one order ticked and the Send and Discontinue buttons

Order sent appears with Undo. The order is now Requested, so it leaves the Draft list.

Clinic orders after sending: the message Order sent with Undo, and only the prescription still listed as Draft

Attach photos and documents

14. Add an attachment

Tap Attachments in the row of views, then Add attachment.

Tap Choose files and pick photos or PDFs: up to 10 MB each, 5 files at a time. Add a Note if you want, then tap Save.

On an iPad you can take a photo with the camera or pick one from your photo library.

You should see: your file listed under Choose files.

The Add attachment form with one image chosen, an optional Note box, and Save

The file appears in the Attachments view. To switch the layout, tap the grid button, then Grid or List.

The Attachments view with one image attachment and the message Added attachment

15. Open an attachment

Tap the picture or file. It opens large, with its name, type, size and the date it was added. Tap ✕ at the top right to close it.

An attachment opened full size: intraoral-photo.jpg, Image, 11 KB, with a close button

Tips

Check allergies before you prescribe

The order sheet shows the patient's allergies under their name. If it says Allergies not recorded, ask the patient and add them in Records › + Allergies (step 3).

If something goes wrong

  • The medicine isn't in the list. Try fewer letters, or the generic name. You can also type the details yourself on the Medicine page.
  • Your licence number is blank on the prescription. Add it in Settings › Profile.
  • You sent an order by mistake. Tap Undo right away. Later, use Discontinue… on the Orders page.

Good to know

  • You can add Lab order and Imaging order only. Older visits may show other kinds of order, but you can't create them.
  • Send marks the order as requested in Dentalemon. It doesn't send anything to an outside lab: give the patient the printout or contact the lab yourself.
  • Photos are made smaller when they're saved, to keep the app quick.

What's next