Chart Note Section Components

These section components are the building blocks for your chart notes. Each one serves a specific purpose to help you document patient encounters accurately and efficiently. Below is a quick summary table of all available components, followed by detailed explanations of each, including how to use them effectively.

Chief Complaint	A simple text box where you capture the patient’s main reason for the visit in their own words.
Vitals and BMI	Dedicated fields for recording vital signs like blood pressure, heart rate, temperature, and more. Enter height and weight, and the system automatically calculates BMI for you.
Notes	A free-text area for any general charting details, observations, or narrative you need to add.
Body Chart	An interactive body diagram where you mark specific areas, add notes to each marking, and draw directly on the chart using freehand tools.
Spine Chart	A specialized spine diagram that lets you add notes for individual vertebrae and draw lines or markings with a freehand tool.
Notepad	A blank canvas for freehand writing or quick sketches—just like jotting notes on paper.
Attachment	An uploader for adding images, files, or documents directly to the chart note (great for scans, photos, or reports).
Checkbox List	A customizable checklist tool. You can create multiple groups of checkboxes to track symptoms, procedures, findings, or anything else with simple check-offs.
Scale	Perfect for pain or severity ratings. Choose a 1-10 scale available in two graphical representations: 1) option buttons, and 2) slider scale.
Table	A flexible grid tool for organizing data in rows and columns (ideal for lab results, medication lists, or structured comparisons).

These components mix and match beautifully. Start with a template or build from scratch – whatever works best for your workflow!

Chief Complaint

This is a straightforward text box for entering the patient’s main reason for the visit. Keep it concise and capture the complaint in the patient’s words or a brief summary. It’s usually placed at the top of the note for quick reference.

Vitals and BMI

Use this section to record key vital signs: body temperature, pulse rate, and respiration rate. You can also enter the patient’s weight and height; the system automatically calculates and displays the BMI right there. This makes it easy to track health metrics at a glance without extra math.

Notes

Just like the Chief Complaint, this is a flexible text box for longer paragraphs or detailed narrative. Perfect for additional observations, history details, or anything that doesn’t fit elsewhere.

To customize it: Click Edit section next to the title, type a new name (e.g., “Subjective History” or “Progress Notes”), and save. This lets you tailor the section label to your workflow.

Body chart

An interactive full-body diagram that lets you draw markings and add numbered annotations with descriptions. Great for highlighting areas of pain, injury, or exam findings visually.

To use:

1. To rename the section: Click Edit section next to the title, enter a new name, and click Save.
2. Select the Drawing tool (it starts selected by default).
3. On the toolbar, adjust the thickness and color of the drawing pointer as needed.
4. Draw directly on the body chart using your mouse or touch input to add freehand markings.
5. Use Undo and Redo on the toolbar to correct the last action.
6. Switch to the Eraser tool to remove specific drawings.
7. To add annotations: Click the the Drawing button again to toggle off drawing mode.
8. Click anywhere on the chart – a circled number appears (starting from 1 and incrementing automatically).
9. In the text box that appears below the canvas, type a description for that point.

[Insert screenshot of the Body Chart with toolbar here]

Spine Chart

A specialized diagram of the spine for adding freehand drawings and notes tied to specific vertebrae. Ideal for documenting spinal exams, pain locations, or findings.

To use:

1. To rename the section: Click Edit section next to the title, enter a new name, and click Save.
2. Select the Drawing tool (it starts selected by default).
3. On the toolbar, adjust the thickness and color of the drawing pointer as needed.
4. Draw directly on the spine chart using your mouse or touch input to add freehand markings.
5. Use Undo and Redo on the toolbar to correct the last action.
6. Switch to the Eraser tool to remove specific drawings.
7. To add notes for individual vertebrae: Click the Drawing button again to toggle off drawing mode.
8. Hover over a vertebra. Options to add a note appear on the left and right sides of the spine.
9. Click the desired side, type your note, then click outside the field or press Tab. The note saves automatically and appears in the Spine notes box, referenced to the specific vertebra.
10. Continue with adding additional information in the Spine notes text box as needed for overall comments or summaries.

[Insert screenshot of the Spine Chart with toolbar and notes here]

Notepad

A blank canvas for freehand sketches, quick diagrams, or handwritten-style notes. Great for drawing pain patterns, simple illustrations, or anything that benefits from visual jotting.

To use:

1. To rename the section: Click Edit section next to the title, enter a new name, and click Save.
2. On the toolbar, adjust the thickness and color of the drawing pointer as needed.
3. Draw directly on the notepad canvas using your mouse or touch input to add freehand markings.
4. Use Undo and Redo on the toolbar to correct the last action.
5. Switch to the Eraser tool to remove specific drawings.

[Insert screenshot of the Notepad canvas with toolbar here]

Attachment

This section lets you upload a supporting document or image directly into the chart note. Useful for attaching referral letters, consent forms, lab reports, photos, or scans.

To use:

1. To rename the section: Click Edit section next to the title, enter a new name, and click Save.
2. Upload a file: Click Browse to select a file from your device, or drag and drop it into the dashed area.
   • Only one file is allowed per Attachment section.
   • Supported formats include document files such as PDFs, Word documents, and images.
3. In the Add file description box, type a clear description of the file (e.g., “Right knee X-ray – lateral view” or “Signed consent form”).
   • Descriptions are searchable, so good keywords make it easier to find the file later when searching chart notes.

[Insert screenshot of the Attachment section with upload area and description box here]

Checkbox list

A customizable checklist tool for tracking symptoms, exam findings, procedures, or any yes/no items. You can create multiple groups, add text boxes for details, and adjust layou – perfect for structured assessments.

To use:

1. Click Edit section next to the title. A modal window opens showing the section name and two checklist groups added by default.
   • To rename the overall section: Type a new name at the top and proceed with customization.
2. Update the section title if needed by typing over it.
3. For each checklist group:
   1. Click the edit icon next to the group name to open its settings.
   2. Toggle Allow textbox fields to add (or remove) a text box next to each checked item for extra details.
   3. Choose Horizontal or Vertical layout using the radio buttons.
   4. If Vertical is selected, pick 1–4 columns to arrange the checkboxes.
   5. Edit labels for individual checkboxes. Use the Add textbox option next to each to add (or remove) a text field.
   6. Remove a checkbox with the remove button next to it.
   7. Add new checkboxes with Add checkbox.
   8. Click Save to confirm changes for that group and return to the main modal.
   9. Repeat for additional checklist groups.
4. If you have only one checklist group and want a cleaner look, check Hide description to remove the group name (leaving just the section title visible).
5. Click Save in the main modal to apply all changes and return to the chart note (or template).

[Insert screenshot of the Checkbox List customization modal here]

This tool keeps checklists organized and flexible. Use groups for different categories (e.g., “Symptoms” and “Exam Findings”) to make notes easy to scan.

Scale

A rating tool for documenting pain, severity, or other metrics on a 0–10 scale (in 1-point increments). You can add multiple scales per section and choose radio buttons or a slider for each.

To use:

1. Click Edit section next to the title. A modal window opens showing the section name and two scales added by default.
   • To rename the overall section: Type a new name at the top and proceed with customization.
2. Update scale descriptions by typing over the existing defaults.
3. Click Add scale to include another rating scale.
4. To remove a scale, click Remove next to it.
5. For a single-scale section, check Hide description next to the scale to show only the section heading (no individual scale label).
6. To change display style: Click Edit scale for the desired scale, then select Radio buttons or Slider.
7. Click Save, then click Save on the Edit scale list modal to return to the chart note (or template).

[Insert screenshot of the Scale customization modal here]

During charting, simply select the rating on the chosen scale (buttons or slider). This makes quick, consistent assessments easy to record and review.

Table

A flexible grid for presenting data in rows and columns. Use it for lab results, medication lists, treatment progress, or any structured information.

To use:

1. Click Edit section next to the title. A modal window opens showing the section name and a table added by default.
   • To rename the overall section: Type a new name at the top and proceed with customization.
2. Adjust the number of rows and columns to fit your needs.
3. Customize appearance with the checkboxes:
   • The first row of the table is the table header – makes the top row bold for column labels.
   • Add notes box underneath the table – adds a text area below the grid for extra comments.
4. Click Save to apply changes and return to the chart note (or template).
5. To fill the table: Click inside any cell and type your text. Edit or add content anytime.

[Insert screenshot of the Table customization modal and an example filled table here]

This section keeps structured data neat and easy to read within your chart note.