Module 7 - Charting

Module 7: Charting - Invoicing, Telehealth, and Messaging

Description

Explore how to use 4D EMR’s workflow tools to streamline daily operations. Learn best practices for charting, invoicing from the schedule, telehealth, and secure messaging.

Key Topics

• Charting features and best practices
• Invoicing from the schedule
• Telehealth setup and use
• Internal messaging and communication
• Patient logs and documentation

Please note: The outlines below are intended to supplement the linked videos and are not standalone documentation.

4D EMR Onboarding 7.0 - Charting Overview (01:21)

Charting Overview 

Overview

4D offers a wide range of charting tools designed to streamline documentation and support efficient clinical workflows.

Most practices use a combination of these features to simplify charting and maintain consistent, high‑quality notes.

This module covers:

• How to create a chart note
• Key charting features available while writing notes
• How to configure tools such as the Physical Exam Wizard and Blurbs
• How to set up Chart Note Types
• How to cosign chart notes
• A full charting walkthrough

Before diving into configuration, let’s review where charting tools live inside 4D.

Accessing Charting Tools

From the Schedule

On the schedule:

1. Right‑click on an appointment
2. Hover over Patient
3. Choose one of the following:
   • Read Chart Notes
   • Write New Chart Note for that appointment

If you choose to write a new note, 4D takes you directly into the chart note editor where you can begin documenting immediately.

Chart Note Heading

• • The heading at the top of the chart note can be customized
  • You’ll learn how to configure this in the Chart Note Types video

From the Patient Tab

You can also access charting tools from the patient’s chart.

Navigate to:
Patients → Select Patient → Clinical Dropdown

Here you can:

• Write a new chart note
• Read existing notes
• Continue drafts
• Cosign notes (if your practice requires cosignatures)

This menu centralizes all charting activity for the patient.

4D EMR Onboarding 7.1 - Charting Features (07:42)

Charting and Features 

Overview

This section walks through how to write a chart note in 4D and introduces all major charting tools available.
You’ll learn how to:

• Start a chart note
• Insert previous notes
• Use chart note templates
• Navigate merge fields, Go To shortcuts, and blurbs
• Use the Drawings Manager
• Create invoices directly from a chart note
• Add signatures and finalize documentation

These tools help practices streamline documentation and maintain consistent, efficient charting workflows.

Starting a Chart Note

From the Schedule

1. Right‑click the patient’s appointment
2. Navigate to Patient → Write Chart Note
3. You’ll be taken directly into the chart note for that appointment

   ---

Chart Note Header

At the top of the chart note, you’ll see:

• • Chart Note Type
  • Patient
  • Demographics
  • Provider
  • Office
  • Location
  • Date of Service

Description Field

• • Add optional details that will appear in the completed chart note list
  • This feature must be activated in settings before use

Using Previous Notes

Insert Note

• Select Insert Note to pull in a previous chart note
• Choose from the list of past notes
• Useful for repeat visits or continuity of care

Using Chart Note Templates

If you created templates in the Forms Library:

1. Select Templates
2. Choose the template you want
3. Select Open

The template will populate into the chart note.

Merge Fields

If your template uses 4D merge fields, the system will automatically pull in:

• Medications
• Allergies
• Surgical history
• Other health information

These fields are based on the patient’s Health Information Form and the Clinical section of the Patient tab.

Form Elements

Templates can include:

• Checkboxes
• Fill‑in fields
• Structured sections

Using the Go To Feature (*)

If your template includes asterisks (*):

• Press F4 (PC) or Fn + F4 (Mac)
• The cursor jumps to the next *
• Type your note
• Press F4 again to jump to the next section

This speeds up charting by guiding you through all customizable areas.

Using Blurbs (Dot Macros)

Blurbs allow you to auto‑fill text using shortcuts.

How They Work

• Type a dot command (e.g., .smoke)
• Press space
• The blurb auto‑fills into the chart note

You can also select blurbs from the Blurbs button in the chart note menu.

Best Workflow

Many practices combine:

• Templates
• Go To shortcuts
• Blurbs

…to complete chart notes quickly and consistently.

Drawings Manager

The Drawings Manager allows you to annotate images and insert them into chart notes.

Accessing Drawings

Select the Drawing icon to open:

• Pre‑loaded anatomical images
• Patient photos
• Imported images (from device or camera)

Drawing Tools

• Pencil Tool — freehand drawing
  • Adjust line size, color, and opacity
• Line Tool — straight lines (solid or dotted)
• Undo — remove last action
• Eraser — remove markings (size 10 recommended for large areas)
• Text Tool — insert text and drag to position
• Stamp Tool — for injectables

Stamp Tool (Injectables)

If injectables are configured:

• Neuromodulators
  • Select product
  • Select units
  • Choose stamp size
  • Tap injection sites
  • Total units appear at the bottom
• Fillers
  • Select product
  • Select number of charges
  • Draw filler placement
  • Total charges appear

Inserting Drawings

• Choose Insert Small or Insert Large
• Once inserted, drawings cannot be edited
• You can resize the image inside the note

Creating an Invoice from a Chart Note

If you used products during the visit:

1. Select the Invoice icon
2. Choose the products/services used
3. Select Save Charges and Insert

This:

• Adds the charges to the chart note
• Creates an active invoice in the Money tab
• Allows front desk staff to collect payment immediately

Signing the Chart Note

Electronic Signature

• Select Sign to electronically sign the note
• The note is stamped with the provider’s name and timestamp

Handwritten Signature

• Select the Signature button to insert your stored signature
• You’ll learn how to upload your signature in a later module

Once signed, the chart note is complete.

4D EMR Onboarding 7.2 - Physical Exam Wizard (04:25)

Physical Exam (PE) Wizard

Overview

The Physical Exam Wizard is one of the most powerful and customizable charting tools in 4D.
It creates an “on‑the‑rails” charting experience that guides providers step‑by‑step through a complete clinical note.

Before using the PE Wizard, you should already be familiar with chart note templates, blurbs, and other charting tools covered earlier in the module.

Accessing the PE Wizard

To begin:

1. Right‑click the patient’s appointment on the schedule
2. Hover over Patient
3. Select Chart Note

Once inside the chart note:

• Navigate to Wizard & More
• This tab contains all wizard buttons and workflow options

You can use every section or mix and match depending on your practice’s needs.

Using the Wizard Sections

Each button in the wizard represents a structured section of the chart note.
You can also use Blurbs within each section to speed up documentation.

For this walkthrough, we’ll select Insert & Next in each section so you can see how the wizard builds the note from top to bottom.

1. Chief Complaint (CC)

• Pulls in the patient’s chief complaint from the appointment
• You can edit, skip, or insert into the note

2. History of Present Illness (HPI)

• Auto‑populates based on the patient’s medical information
• Pulls from the Medical History tab
• Edit as needed

3. Past Medical History

• Displays the patient’s medical history
• Edits here update the patient’s entire chart

4. Past Surgical History

• Review or add surgeries
• Add hospitalizations if applicable

5. Medications

• Lists current medications
• Add, remove, or modify as needed

6. Allergies

• Review and update allergy information

7. Review of Systems (ROS)

• Select items to include
• If nothing applies, choose Insert & Next
  • The system will mark ROS as non‑contributory

8. Social History

• Review and update lifestyle and social factors

9. Family History

• Review and update family medical history

10. Vital Signs

• Review and edit vitals if needed

After inserting vitals, the Physical Exam Wizard appears.

Physical Exam Wizard

4D provides a default PE Wizard that you can test and customize.

How It Works

• The exam is divided into regions (e.g., face, abdomen, extremities)
• Selecting a region displays the exam items for that area

Item Types You Can Configure

• Checkboxes
• Free‑text fields
• Single‑select options
• Multi‑select options
  • Example: multiple descriptors for nasal tip findings

You can use as many or as few regions as needed based on the patient’s visit.

Once complete, select Insert & Next.

Assessment and Plan

After the physical exam:

Assessment

• Document your clinical assessment
• Select Insert & Next

Plan

• Document your treatment plan
• Select Insert & Next

Finalizing the Chart Note

As you progress through the wizard:

• Each section automatically drops into the chart note
• The note builds from top to bottom in a structured, consistent format

After completing the wizard:

• You may continue using other charting tools (templates, blurbs, drawings, invoices, etc.)
• Sign the note to finalize it

What the PE Wizard Enables

The PE Wizard allows you to build highly structured exam sections using:

• Freehand text
• True/false statements
• Single‑choice and multi‑choice options
• Checkboxes

It ensures consistency, reduces typing, and guides providers through a complete exam workflow.

4D EMR Onboarding 7.3 - Customizing PE Wizard (02:50)

Customizing the Physical Exam (PE) Wizard 

Overview

If you’ve decided to use the Physical Exam Wizard, the next step is configuring it to match your practice’s clinical workflow.
4D provides a comprehensive default wizard, but many practices prefer to simplify or customize it based on the regions they examine most often.

This section walks through how to build and modify your own PE Wizard from scratch.

Accessing the PE Wizard Setup

Navigate to:
Practice → Charting → Physical Exam Wizard

The setup is divided into two tabs:

• Area Categories
• Physical Exam Items

Step 1 — Create Area Categories

Area categories represent the anatomical regions or exam sections you want to document.

Creating a New Area

1. Select + New Area
2. Enter the name of the category (e.g., “Nose,” “Breasts,” “Abdomen,” “Skin”)
3. Save the category

Once created, you can begin adding exam items to that area.

Step 2 — Create Physical Exam Items

Navigate to the Physical Exam Items tab.

1. Select your area category from the dropdown
2. Select + New to create a new exam item

A new window will appear where you can:

• Add the item description
• Choose the item type
• Add response options (if applicable)

Each item type includes a brief explanation of how it behaves in the wizard.

Item Types and How to Use Them

1. Single‑Selection List

• Used when only one answer should be selected
• Begin with the first part of the sentence
• Add each selectable option below

Example:
“Tip position is…”

• Upturned
• Neutral
• Drooping
• Deviated
• Over‑projected

2. Multi‑Selection List

• Allows selecting multiple responses
• Setup is identical to single‑selection lists
• Useful for findings with multiple descriptors

3. True/False Statements

• Recommended phrasing:
  • “There is…”
  • “There is no…”

Good for documenting presence or absence of findings

4. Checkbox Items

• Creates a single checkbox with text
• Commonly used for:
  • “Within normal limits (WNL)”
  • “No abnormalities noted”

Step 3 — Save and Test Your Items

After adding all needed responses:

• Select Save
• Your item will now appear under that region when using the PE Wizard in a chart note

Repeat this process until all items for the region are complete.

Using Your Customized Wizard in Chart Notes

Once configured:

• Open a chart note
• Navigate to Wizard & More
• Select your region
• Your custom items will appear
• Insert findings directly into the note as you progress

This creates a fast, structured, and consistent documentation workflow.

Notes

• The PE Wizard requires an initial time investment to build
• Once complete, it dramatically reduces charting time
• Providers can focus more on patient care and less on typing
• You can create as many regions and items as needed to match your specialty

4D EMR Onboarding 7.4 - Creating Blurbs (01:21)

Creating Blurbs

Overview

Blurbs are short, customizable text shortcuts—often called dot macros—that allow providers to quickly insert commonly used phrases into chart notes.
They dramatically speed up charting and can be used alone or combined with templates and the Physical Exam Wizard.

Creating blurbs is a simple two‑step process.

Step 1 — Create a Blurb Category

Navigate to:
Practice → Charting → Blurbs

If no blurbs exist yet, you’ll see an introductory blue box explaining what blurbs are.

Before creating blurbs, you must create at least one category. Categories help organize your blurbs.

Common Category Examples

• Face
• Body
• Pre‑Op
• Post‑Op
• Injectables
• Procedure‑specific categories (e.g., “Rhinoplasty,” “Liposuction”)

Create a Category

1. Select + New Category
2. Enter the category name
3. Save

Once the category is created, you can begin adding blurbs.

Step 2 — Create Blurbs

Navigate to the Blurbs tab.

1. Select your category from the dropdown
2. Select + New
3. A new window will appear where you can enter:
   • Blurb Text — the full sentence or paragraph you want to auto‑insert
   • Shortcut Name — the trigger you’ll type in chart notes

Shortcut Naming Guidelines

• Use 3–5 letters
• No punctuation or symbols required
• Example:
  • Shortcut: smoke
  • Blurb text: “Patient denies tobacco use.”

Save the blurb, and it will appear in your list.

You can create as many blurbs as needed.

Using Blurbs in Chart Notes

When writing a chart note:

1. Type a dot followed by the shortcut
   • Example: .smoke
2. Press space
3. The blurb text automatically inserts into the note

You can also select blurbs manually using the Blurbs button inside the chart note editor.

Workflow Tips

1. Blurbs + Templates

Many practices build chart note templates that include:

• Asterisks (*) for F4 navigation
• Blurbs for quick text insertion

This combination creates a fast, structured charting workflow.

2. Blurbs‑Only Charting

Some providers prefer to:

• Insert a blank template
• Use blurbs for most of the note
• Free‑type only the unique details

This is especially popular for high‑volume practices.

4D EMR Onboarding 7.5 - Cosign Notes (01:27)

Cosign Notes

Overview

Some practices require providers to cosign chart notes written by staff members.
This workflow ensures clinical oversight and maintains documentation standards.
Cosigning is optional—only enable it if it fits your practice’s needs.

This section covers:

• How to configure chart note types that require cosignatures
• How the cosign workflow functions for staff and providers
• How providers can batch‑cosign multiple notes

Configure Chart Note Types for Cosigning

Navigate to:
Practice → Settings → Chart Note Types

For any chart note type that requires a provider cosign:

• Check the box Provider Must Sign
• Save your changes

Only chart notes with this setting enabled will enter the cosign workflow.

Staff Workflow

When a staff member writes a chart note:

1. They complete the note as usual
2. Select Sign & Finish
3. Their part of the note is complete

Once signed, the note is automatically routed to the provider for review.

Provider Workflow

When the provider logs in:

• A notification appears in the top‑right corner (next to their name)
• This indicates that chart notes are waiting to be cosigned

Cosigning a Single Note

1. Select the chart note from the notification list
2. Review the documentation
3. Select Sign & Finish

The note is now fully cosigned and complete.

Batch Cosigning

If multiple notes require cosignatures:

1. Open the list of pending notes
2. Toggle the checkbox next to each note
3. Select Cosign

This allows providers to sign multiple chart notes at once, saving time during busy clinic days.

4D EMR Onboarding 7.6 - Vitals (00:56)

Vitals

Overview

Vital signs can be updated before or after writing a chart note.
This section explains how to record and manage vital signs in 4D and how they integrate with chart note templates.

Accessing Vital Signs

Navigate to:
Patients → Select Patient → Clinical Dropdown → Vital Signs

This opens the patient’s most recent vital sign entry.

Adding New Vital Signs

1. Select + Add New Intake

2. Enter the patient’s:

• Height
• Weight
• Blood pressure
• Pulse
• Any other available fields

1. Select Save

Once saved:

• BMI is automatically calculated
• SNUR scale is automatically calculated (if applicable)

Using Vital Signs in Chart Notes

If your chart note templates include the Vital Signs merge field:

• The most recent vital signs recorded in the system will automatically populate into the chart note
• This ensures accurate, up‑to‑date vitals appear in every note without manual entry

4D EMR Onboarding 7.7 - Note Differences (01:38)

Note Differences

Overview

4D offers two different ways to write chart notes:

• Appointment Notes — tied to a scheduled appointment
• Insta Notes — used when no appointment exists

Understanding when to use each option is essential for accurate reporting, clean documentation, and proper invoicing.

Writing Notes for Scheduled Appointments

For patients who have an appointment on the schedule:

1. Right‑click the appointment block
2. Hover over Patient
3. Select Write Chart Note

This is the recommended workflow for all scheduled visits.

Why This Matters

• Ensures the note is correctly linked to the appointment
• Supports accurate reporting
• Allows invoice creation when needed
• Keeps documentation organized and tied to the patient’s visit history

Writing Notes Without an Appointment

If a patient does not have an appointment or you need to document a clinical note unrelated to a scheduled visit:

1. Navigate to Patients
2. Pull up the patient’s account
3. Select the Clinical dropdown
4. Choose Write Note

A window will appear with two categories:

• Left side: Appointment‑based note types
• Right side: Insta Notes

Use Insta Notes only when:

• The patient comes in without an appointment
• You need to document a clinical interaction not tied to a scheduled visit
• You are recording a note for administrative or non‑visit purposes

Important Limitations

• You cannot create invoices from Insta Notes
• Using Insta Notes for scheduled appointments can cause errors and reporting issues

Customizing Insta Note Categories

If your practice needs additional Insta Note types:

• You can modify or add categories
• This is done in Chart Note Types (covered in a previous video)

Best Practices

Use Appointment Notes When:

• The patient has a scheduled appointment
• You need to create an invoice
• You want accurate reporting and visit tracking

Use Insta Notes When:

• The patient has no appointment
• You need to document something unrelated to or supplemental to a scheduled visit

4D EMR Onboarding 7.8 - Chart Note Type Settings (04:15)

Chart Note Type Settings 

Overview

Chart note types determine:

• The headings that appear on chart notes
• Which notes require provider signatures
• Which notes require special permissions
• How Insta Notes behave
• Which chart note type is linked to each appointment type

Because chart note types affect multiple areas of 4D, it’s important to configure them carefully to match your practice’s workflow.

Accessing Chart Note Types

Navigate to:
Practice → Settings → Chart Note Types

This page displays:

• All Insta Note categories
• All chart note headings
• Toggle‑based settings that control permissions, signatures, and note behavior

Key Settings and What They Do

Require Clinical Notes Permissions

• Limits visibility of certain note types
• Only users with the appropriate permission can view or write these notes
• Useful for sensitive note types (e.g., mental health, confidential communications)

2. Provider Must Sign

• Requires a provider to sign the note
• If unchecked, any staff member can sign
• Recommended for:
  • Operative reports
  • Pre‑op visits
  • Surgical follow‑ups
• Optional for:
  • Medication notes
  • Email documentation
  • Administrative notes

3. Include Post‑Op Line

Adds a line at the top of the chart note showing:

• How many days post‑op the patient is
• The procedure performed
• The date of surgery

This is helpful for surgical follow‑ups.

4. Universal Draft

By default, only the original author can edit their chart note.

Turning on Universal Draft allows multiple staff members to contribute to the same note (one at a time).

Common Workflow Example

1. Patient Care Coordinator starts the note → saves draft
2. Nurse adds clinical details → saves draft
3. Provider completes and signs the note

This workflow is powerful but must be used carefully.
Work with your project manager to ensure it fits your practice.

5. Add Logo to Note

• Automatically places your practice logo at the top of every chart note
• Requires your logo to be uploaded during Basic Setup

Chart Note Types in Appointment Types

Chart note types also determine what note is created when an appointment begins.

Navigate to:
Practice → Admin → Scheduling → Appointment Types

1. Open an appointment type
2. Scroll to Chart Note Type to Write for This Appointment
3. Select the appropriate chart note type from the dropdown

Examples

• Injectable appointment → Injectable chart note type
• Pre‑op appointment → Pre‑op chart note type
• Post‑op appointment → Post‑op chart note type

You can also configure whether a chart note should automatically open a template from the Forms Library.

Recommended Setup Process

Step 1:

Navigate to Practice → Settings → Chart Note Types

Step 2:

Delete note types you do not need using the trash can icon

Step 3:

Create new chart note types using + New

Step 4:

Enable any toggle settings that fit your workflow:

• Provider Must Sign
• Require Clinical Notes Permissions
• Include Post‑Op Line
• Universal Draft
• Add Logo to Note

Step 5:

Navigate to Practice → Admin → Scheduling → Appointment Types
Link each appointment type to the correct chart note type.