Clinical record and treatment

“Open visit” takes you straight to “Treatment”, with that appointment's visit on screen. The record's tabs:

Above the tabs, on every tab, sits the clinical warnings strip — see the warnings strip.

Each step builds on what was entered in the step before, so nothing is entered twice. Only rows of an accepted plan can be booked and show up at the visit. For each visit, form 043/e (the Moldovan dental patient record) is then filled in and generated.

The confirmation window shows what is being completed and “To collect”. From this moment, what is completed becomes a debt, and reception sees it at checkout. What is “In progress” or “Planned” stays in the plan for next time.

• What you add with “+ Procedure done today” shows separately, “Outside the plan”; the accepted plan stays as the patient accepted it.
• A new problem, to treat another time: “Add to plan” — it goes into the accepted plan, unscheduled.

What changes on the dental chart. The app reads the procedure's name and puts its result on the tooth: “Composite filling 26” removes the caries from 26 and adds a filling, an extraction leaves the tooth extracted, an implant leaves the implant. A green check appears on the “Dental chart”. Anything that cannot be inferred from the name (for example an orthodontic mini-implant) doesn't change the tooth — mark it by hand.

The wallet icon also opens the payment right away. “New visit” also puts the visit in the calendar. The “Status” list on the row is available to whoever writes the plan (“Propune plan de tratament” — Propose treatment plan); the wallet icon to whoever collects payments. The assistant, who has neither, marks the procedure on their own visit, with “Done — send to reception”.

It's the same note as on the calendar appointment — written in one place, it shows in the other. It requires the right to edit appointments. Clinical work goes in form 043/e, not in the note.

The appointment becomes “Completed”, with nothing to collect and without requiring form 043/e.

The window shows what is added to the debt and what is taken off it. Payments already made stay on their procedures, and a paid procedure can no longer be removed. If the visit's form 043/e was finalized, it reopens and you finalize it again.

There is no save button: the editor shows “Saves itself”, then “Saved”, and the tooth is redrawn on the spot. Numbering is FDI (11–48 for adults, 51–85 for primary teeth). A tooth can carry several marks (caries next to an old filling); click one under “On the tooth:” again to remove it. Problems (caries, pulpitis) are colored red, work already done (filling, crown) blue.

The editor shows “Dinți 14, 15, 16” (Teeth 14, 15, 16). Shift selects the whole range along the arch.

M mesial · O occlusal · D distal · V vestibular · L lingual.

Each observation keeps who wrote it.

To remove just one mark, click it in the editor's “On the tooth:” row.

The films and photos linked to that tooth appear; if an imaging study has a signed report, “Signed report” is shown. “Add” uploads an image that links itself to the tooth, and “Foto” (Photo) takes a photo.

“Mixed” is for children aged 6 to 12, who have both primary and permanent teeth. Once the first tooth is marked, the chart picks the dentition by itself.

Separate charts show change over time; switch between them with the tabs above the chart. The pencil renames a chart, the trash can deletes it.

Each problem becomes a row, with the matching service from the price list and its price. For a plan with no rows, click “Empty plan” and fill it in the table. The plan saves itself (“Saved automatically”) — there is no save button.

The button becomes “✓ Accepted”, and the plan gets the label “ACCEPTED BY PATIENT”; the others show as “proposed option”. Several plans can be accepted at once (for example a restorative one and a prosthetic one). Only rows of an accepted plan can be booked and show up at the visit, in “Treatment”. It requires the “Aprobă tratamente” (Approve treatments) right.

The patient and procedures are already chosen, and the price comes from the plan. The appointment stays linked to the plan rows: at the visit, the procedures are already on it.

• In “Choose from the catalog”, services matching the diagnosis come first.
• The “Urgency” column has “Urgent”, “Priority” and “Can be postponed”.
• “Modify the procedure” also has “Plan” (which plan the row is in) and “Delete”.

The price changes only with “Editează prețul în planul de tratament” (Edit the price in the treatment plan). On a procedure already paid, the window shows “Paid so far:” — the cost cannot go below that amount, and the procedure cannot be deleted without reversing the payment.

Each plan is a tab above the table. The list next to the name changes the plan's specialty (“Ortodonție” (Orthodontics), “Tratament terapeutic” (Restorative treatment), “Tratament protetic” (Prosthetic treatment), “Chirurgie, Parodontologie, Implantologie” (Surgery, Periodontology, Implantology)), and the row of specialties above filters the plans. The header shows the total and the progress (for example 4/6 procedures completed).

The new plan keeps the prices and discounts, and the old one stays in the record as an option. Only procedures not yet started are moved.

The discount is applied to each procedure's price (the list price appears struck through next to it, with “−10%”), not as a separate line. No procedure goes below what has already been paid on it. It requires “Editează prețul în planul de tratament” (Edit the price in the treatment plan).

The sections are “Patient data”, “Dental chart”, “the plan's notes”, “the total” and “the signature fields”. The same list may go to the patient, to the lab or to the file, so choose each time what goes in (for example without the “Doctor” column). Printing is logged in the record's journal.

The payment plan for its estimate opens. Installments, the deposit and payment collection are explained in the section on payments.

Ticked rows move together. The order is both the one the patient sees on the estimate and the one in “Unscheduled — in plan order”.

The row sits between procedures, with no price, and appears on the estimate under “the plan's notes”.

The patient, the work, the teeth and the doctor come from the row. It requires “Trimite lucrări la laborator” (Send work to the lab).

The rows go to Journal → Deleted, from where they can be restored. A plan with completed procedures cannot be deleted.

“Allergies on record:” shows above the form. If a medication resembles a recorded allergy, the app stops you and asks for “I have read it and prescribe anyway”.

Prescription templates are written in Settings → Services → Prescription templates. Issuing requires “Emite rețete” (Issue prescriptions).

The prescription leaves the record with its reason; the paper given to the patient stays with them.

The “Treatment · 043/e form” page opens, with the chosen visit. “Visit type”: “Primary”, “Secondary”, “Prophylactic”. The sections: “Complaints”, “Past and concurrent diseases”, “Course of the current illness”, “Objective findings, external examination”, “Examination of the oral cavity. Condition of the teeth”, “Occlusion”, “Mucosa condition · oncological vigilance”, “Radiological / laboratory investigation data”, “Anesthesia (BP, RR, HR, t°, SpO2)”, “Treatment”, “Treatment results (epicrisis)”, “Recommendations”.

On the right, “The teeth's condition at this visit” shows what changed on the teeth today; you can select teeth and “Set the state” right there. On the visit, in “Treatment”, you see “record filled in” or “record not filled in”.

In the template's texts, “#” becomes the tooth number. If the sections already have text, the app asks before replacing it; “Keep what I wrote” cancels. If the template also implies procedures, the message “The “…” template also implies …” appears, with “Open in Treatment”: there the procedures are proposed on the visit and confirmed with “Done — send to reception”. Templates are written in Settings → Services → Visit templates.

For a check-up with no complaints, use Z01.2. A finalized form can no longer be edited; to correct it, click “Redeschide” (Reopen).

“Digital signature” appears only if you have saved your signature in My account. Under “Zilnic / Дневник” (Daily log) you see each treatment day, put together from what the app knows; click a day to write the clinical wording instead of the summary.

The form gets a new number, unique in the clinic, and its PDF is kept: open it with “Print” or save it with “Download”, as many times as you like — the same file. Forms generated earlier are not deleted.

It is the whole patient's form — the dental status from the first visit and all visits under “Zilnic” (Daily log) — the one handed to the patient, at discharge or on request.

You also find them on the form's page, under “Generated 043/e forms”. Each has its number and the PDF kept at generation. The clinic's registers (039-1/e, 069/e, 074/e…) are in Reports → “Medical registers”, for anyone with access to reports.

The form doesn't disappear: it is marked deleted, with the reason and who deleted it.

The risks (“Anticoagulante / antiagregante” (Anticoagulants / antiplatelets), “Bifosfonați / antiresorbtive” (Bisphosphonates / antiresorptives), “Stimulator cardiac” (Pacemaker), “Sarcină” (Pregnancy) etc.) go into the warnings strip by themselves, on every tab and in the calendar. Medication is recorded separately, in “Current medication”, and the general warning in the patient's alert.

“revizuită azi” (reviewed today) appears next to the title; after a year without a review, the date is highlighted, so you know to ask again. All versions stay under “History”, with the date and who reviewed it.

The allergy appears on the strip, on the appointment and in the prescription window. Delete one only if it was entered by mistake.

The risk (anticoagulant, bisphosphonate) then appears on the warnings strip. When the patient stops taking it, click “Stopped it”.

The same strip appears in the calendar, on the appointment, on the treatment page and in the window where a procedure is completed. Anyone who can't see the clinical record (reception, for example) sees only the allergies, the alert and the contraindications. Closing requires “Editează fișa / istoricul” (Edit record / history); if you're not sure, leave it — an extra warning costs one question.

A note can't be deleted: if you made a mistake, click “Edit”, type the correct text and “Save the correction”. It shows that it was corrected and what it said before — the record is a medical document.

The card gathers the appointments (“Finalizate” (Completed), “Viitoare” (Upcoming), “No-shows”, “Anulate” (Cancelled)), the accepted plan, “To pay”, the medical history review date, the blood type and the allergies.

The diagnosis: “Angle class — right” and “— left”, “Overjet (mm)”, “Overbite (mm)”, crowding on each arch, “Crossbite”, “Open bite”, “Deep bite”, “Midline deviation (mm)”, “Facial profile”, “Diagnosis notes”. The appliance: “Appliance type”, “Arches”, “Bonded on”, “Planned duration (months)”, “Appliance details”.

A patient has only one open case at a time. The case header shows the appliance, months in treatment against those planned, the next visit and the current wires. If they exist, the aligner schedule, studies with “Cephalometric analysis” and “Orthodontic photo albums” also appear here. “Edit case” changes the details at any time. Writing requires “Editează fișa / istoricul” (Edit record / history).

The window comes filled in with the current wires and the case's doctor, so type only what changed. Under “Appointment”, link the visit to the calendar appointment the patient came to. In the header, “Next visit” is calculated from the last visit and is highlighted once it has passed; below, you see whether the patient already has a time in the calendar — the booking itself is made in the calendar.

The pencil on a row edits a visit, the trash can deletes it (with a reason; it can be restored from the recycle bin).

With retention, the case moves to “In retention”; without it, it closes on the debond date. A “Debond” row is written to the log automatically. After debonding, the “Retention” button changes the retention type or notes.

The case moves to “Finished” with today's date and can be reopened from “Edit case”. “Delete case” (with a reason) is only for a case opened by mistake: it goes to the recycle bin, from where it can be restored. A patient with several cases has them as tabs at the top.

If nothing opens, allow pop-ups for the app. Printing is logged in the record's journal.

Six sites per tooth. It saves itself (“Saving…”, “Saved”). A new exam takes the missing teeth and implants from the previous one; on a tooth, the list under the number marks it “missing” or “Implant”. A completed exam can no longer be changed.

Above the chart, the mean depth, the sites over 4 and 6 mm, and the bleeding and plaque percentages are calculated. Compared with the previous exam, the app tells you how many sites got deeper or improved, outlined in red or green. The stage and grade are set by the doctor.

The photo is linked to the tooth, appears below its editor and stays in “Record” → “Images”. Without a camera, use “From a file”. It requires “Editează fișa / istoricul” (Edit record / history).

The thumbnails stay on the procedure's row.

From now on, the first press takes the photo and the second keeps it — no mouse needed. “Change” and “Forget” redo or clear the learning. The setting is per computer, so it is done once in each operatory.

The badges: “photo consent”, “without photo consent”, “photo consent undecided”. The purposes: “In the record and for the treating team”, “At courses and presentations, without face and name”, “On the clinic's page and in its materials”.

If the mouth isn't found automatically, mark the pupils, the mouth corners and the lip outline by hand. The simulation can be added to the treatment plan (“Add to the treatment plan”, as a separate proposed plan), sent to the patient portal or exported as a “Laboratory sheet”. If the patient declined photo consent, the simulation is shown only in the operatory.

Reception doesn't see the clinical record, but sees the warnings strip, the dental chart and the same visits here. From here they can also correct the contact details, with “Patient data”, and send an SMS, with “SMS”. Under “Administrative details” are the linked people, consent to messages and portal access. The plan can't be changed from here, and documents to sign stay in the clinical record.

Each job appears with its stage and due date, marked “late” or “attended ✓”. The card appears when the clinic has the lab module and your role can see the lab.

If a kit used on the patient came out of a cycle with “the failed test”, the card flags it. The kit also appears under that day's appointment. It requires “Vede evidența sterilizării” (View sterilization records) and, to record, “Înregistrează cicluri și truse” (Record cycles and kits); the card exists only if the clinic uses the Stock module.

Each completed procedure appears with the date, the plan, the doctor and the price — the answer for a doctor taking over a patient from another. Above it, “Istoric programări” (Appointment history) filters by doctor and by service; an opened line shows the appointment's note and “Open the visit in Treatment”.

Each completed job appears with its cost, how much was paid and the balance. On the plan row, “outstanding” next to the price shows the same thing. Payment collection, installments and the deposit are explained in the section on payments.

The names are those in Settings → Team → Roles & permissions:

By default, the doctor has all of them. The assistant sees the record and can mark procedures done, but doesn't write the plan or edit the dental chart. Reception doesn't see the clinical record; they work on the treatment page.

“Vestibular”: the teeth seen from the front, with the root. “Double view”: the occlusal surface on top, the profile below. The choice applies to the whole clinic, so only those with “Modifică setările” (Change settings) see it.

The change applies to the whole clinic. The full list is maintained in Settings → Services → The dental chart catalog. Both require “Modifică setările” (Change settings).