Dental Contact Note
Readiness: In development · Profile version 0.4.5.
Open Dental Contact Note profile on Simplifier
The authored note preserves the clinician's narrative and reasoning for one contact. Structured findings, measurements and procedures remain available as their own records.
Narrative and structured records
A short contact can have one brief section; a more complex contact may need several sections. Record the relevant history, findings, assessment, care, advice and follow-up. The profile does not require one fixed journal template.
Clinical facts can appear in both narrative and structured records when needed for comprehension. Do not generate unsupported diagnoses or treatments from free text merely to fill section.entry. These links identify selected supporting records, not an exhaustive inventory of the contact.
Encounter.text describes the contact resource; it is not a substitute for the authored journal note. Appointment descriptions are booking information.
For relevant advice, preserve the main content actually given and who received it. Include patient preferences, consent or refusal concerning the specific care, and clinical reasoning where needed. Instructions on a request do not prove that information was delivered. A clinical capacity assessment concerns the particular decision; it is not inferred from a diagnosis or age alone.
Narrative can document these facts, but an authored note does not by itself enforce information-sharing restrictions or establish a complete consent/disclosure workflow. Those require an agreed exchange policy and system handling.
Contact time and document lifecycle
One contact can have several independently authored notes. Finishing the Encounter does not establish that every note is final. A later editing time describes the document, not a new clinical contact.
Preserve the identifier of the same logical note when it is amended. An attestation records an actual attestation event; do not infer one from the note's final status or import time. Attestation metadata alone is not a cryptographic signature.
Examples
A formal FHIR document Bundle is a separate exchange format. Creating or storing a Composition does not by itself create that complete document package.