Doc Alert names the native physician-review process on the Ultrasound section. A custom chart document uses its template's workflow name; Approvals is the review inbox. A separate visit provider review is not a Doc Alert.
Configure a multi-step approval workflow for a custom chart type. Custom chart documents use their configured review workflow. With the Premium subscription, you can switch a custom chart template to a custom chain of approval steps.
This article covers the approval chain itself. For how custom chart templates are created and gated on the Premium plan, see Custom Chart Templates.
Every chart, whether it uses the default document review workflow or a Premium custom chain, follows the same lifecycle:
1. Draft. Staff fill in the chart. While a chart is in draft, its status cannot be changed by editing the record directly, use the Mark Completed action described below.
2. Mark Completed. Staff choose Mark Completed on the draft chart. What happens next depends on the chart template:
• If the template is set to auto-send on complete and has a usable review workflow, completing the chart automatically starts the review, the chart moves straight to In Review and the appropriate reviewer is notified.
• Otherwise, the chart rests at Completed. Notes can still be added while a chart is completed or in review.
3. Send for review. If a completed chart did not auto-send, staff choose Send for review to start the workflow explicitly. This is also how a chart that was returned for corrections gets re-submitted after edits, either from the chart itself, or with one click from the Corrections requested panel in the submitter's Approvals queue, either through the same action on the chart or the Resubmit for review button on the item in the Approvals. See Chart Sign-Off: Setup, Review, and Reminders.
4. In Review. The chart is locked to Notes-only edits while a reviewer works it, either the default document review reviewer or the steps in a Premium custom chain.
5. Signed. Once the last approval is recorded, the chart is signed and becomes read-only. See Locked Records and the Addendum Flow for how to correct a signed chart.
A reviewer who denies a chart, or returns it for corrections, sends it back to draft automatically so staff can revise it and send it again. A returned chart also shows up in the submitter's Submitted by me queue in the Approvals until it's fixed and resubmitted.
Each chart template has an Auto-send for review on complete setting (Settings > Care Settings > Charts > open the template). When this is on, marking the chart complete skips the separate Send for review step and starts the review right away. Check the individual document template's setting. This setting does not control the native Ultrasound section's Send to Physician action.
• Premium plan required. If your plan does not include the Premium charting capability, the Approval Chain section is read-only and shows an upgrade message.
• Custom templates only. Built-in chart templates always use the default document review workflow and cannot be switched to a custom chain. Creating or editing a custom template itself also requires Premium, see Custom Chart Templates.
• Linear, simple chains. Steps run in order. There is no branching or conditions.
New chart reviews use the linked, enabled custom approval chain when one is configured. An existing returned execution retains the workflow from its original submission when resubmitted.
• Go to Settings > Care Settings > Charts.
• Open a custom chart template, or clone a built-in template to start one. See Managing Chart Templates for the template list, activating/deactivating templates, and cloning.
• In the Approval Chain section, choose Default workflow or Custom approval chain.
• You can still rename a built-in template, change its icon, or turn it on/off for your organization from the same Chart Templates list. Its underlying chart type (for example, Vitals, Provider Note, Intake, Ultrasound, STI Test, or Pregnancy Test) cannot be changed, and it cannot claim the type of another built-in.
• Any name, icon, or active/inactive change you make to a built-in applies only to your organization. Other organizations continue to see that built-in's original name, icon, and default active status, unaffected by your changes.
• Behind the scenes, your first edit to a built-in creates your organization's own version of it. The shared default that other organizations use is never modified.
• Name: Optionally give the chain a name to help your team recognize it in Workflow Settings.
• Steps: Add one or more approval steps. For each step choose:
• Approver: assign to a Position or to a specific user. The person or Position you pick must already exist in your account, saving fails with an error if it does not.
• Timeout: set the due time in hours for that step. This must be a positive number.
• Order: Arrange steps into the order they should run.
• Notify on completion: Optionally pick a Position or a specific user to notify when the last approval is recorded.
• When set, CoolFocus creates a task for that target.
• If you choose a specific user, a notification is also sent to that user. Picking a Position only creates a task for that Position's team members, it does not send an email or text.
• If you turn on notifications you must also choose who to notify, leaving the target blank is not allowed and Save is disabled until you pick a target.
• Each step assigns an approval to the selected user or to everyone currently holding the selected Position.
• Approvers work their items from their review surfaces. Physician steps appear in the Approvals, and pending approvals also appear on the Home screen and in the Approvals's Awaiting Approvals queue, where clicking one opens the review directly.
• The Approvals also has a History queue for items already responded to, and a Submitted by me queue for executions the current user started, including any charts sent back for corrections. Each queue can be filtered by status (Pending, Approved, Returned, Denied, Cancelled).
• Once a step's decision is recorded, the reviewer panel on that item shows Decision recorded rather than an outstanding reviewer count.
• While a chart is in review, the chart content is locked. Notes remain editable, and saving them works normally, until the final sign-off.
The Approvals area has a Charts list in the left sidebar, with a Pending, a Mine, and a History queue above it. Each chart in that list shows a count next to its name, and what the count means depends on which queue is currently active:
• Pending: the count is approvals waiting on you right now, across every chart type.
• Mine: the count is approvals still pending on chains that you started, so you can see what you are still waiting on other reviewers for.
• History: no count shows next to a chart. Items here are already decided, so a number there would not represent anything actionable.
These counts update as soon as an approval is decided, so switching between Pending and Mine, or approving or denying an item, keeps the sidebar in sync without needing to reload the page.
When a chart is sent for review, whether by the explicit Send for review action or automatically on complete, CoolFocus now checks whether the reviewer it resolves can actually be reached, for every chart type, not just Ultrasound:
• No reviewer can be found at all. If nothing resolves, no assigned user, no one holding the configured or clinical-reviewer Position, and no physician on file, the send is blocked with an error and the chart stays in its current status. This is expected for organizations that have never needed to configure a reviewer, for example a counseling-only organization; add a reviewer (or assign the position) before sending.
• A reviewer resolves but has no email on file. The send still succeeds, and the chart moves to In Review as usual, but you'll see a warning that the reviewer will not be alerted automatically. In this case, let the reviewer know directly that a chart is waiting for them, since they won't get a system notification.
• A reviewer resolves and has an email on file. The send succeeds with no warning, same as before.
This check looks at the same reviewer your organization's workflow would actually assign, including a specifically selected physician (for example, on an Ultrasound chart) or a staffed, flagged clinical-reviewer Position, so the warning (or block) reflects who would really receive the review.
• The Approval Chain section shows whether the linked chain is currently active. A warning appears, with a "Disabled in Workflow Settings" badge, if the underlying workflow template has been deactivated or its configuration disabled in Workflow Settings, since new reviews will not be routed through an inactive chain.
• If a step's assigned Position or user no longer exists in your account (for example it was deleted after the chain was saved), that step shows a "missing target" badge so you can spot and fix it.
• If a chain was customized directly in Workflow Settings beyond what this simple editor can represent (for example, extra step types), the section becomes read-only here with a message asking you to edit it in Workflow Settings instead. This prevents this editor from silently overwriting those customizations.
• The timeout you set for each step drives reminders and overdue escalation for that step.
• See Chart Sign-Off: Setup, Review, and Reminders for how reminders and escalation work, and how the Approvals queues and status filter work for reviewers and submitters.
• You can update the steps, timeouts, and notify target at any time. Unsaved edits are protected: if the chain refreshes in the background while you are still editing, your in-progress changes are not overwritten.
• Because the review engine reads a chain's steps live rather than from a fixed snapshot, editing the steps of a chain that already has in-progress (live) approvals changes what happens next for those in-progress charts too, from their next step onward. It does not retroactively change a step that has already been approved.
• Removing a chain, or switching back to Default workflow, or reverting unsaved edits, all ask you to confirm first. If the chain currently has in-progress (live) approvals, you are shown how many before you confirm. Unlike editing steps, removing or switching away from a chain does not change those in-progress approvals, they finish out on the chain's original steps; only new send-for-review actions start using the default document review workflow.
• To stop using a custom chain for a template, switch back to Default workflow. New send-for-review actions for that chart type use the default document review workflow.
• The Chart Templates list page only offers Deactivate, not Delete, for exactly this reason: deactivating hides the template from new use without any risk of losing history.
• If you delete a custom template through a grid or API action elsewhere, CoolFocus checks whether anything still references it first:
• If chart entries have been recorded against the template, the delete is blocked with a message telling you the template has chart entries and to deactivate it instead.
• If the template is linked to one or more appointment types, the delete is blocked with a message telling you to unlink it first, or deactivate it instead.
• If nothing references the template, deleting it is a soft delete: the template is marked deleted and inactive, and it disappears from your list, but the row itself is preserved rather than permanently erased.
• Deleting your own override of a built-in template (one where you customized a built-in chart type) simply reverts that chart type back to its built-in default. It does not remove the built-in chart type itself.
• When in doubt, deactivate a template instead of deleting it. Deactivating is always safe and fully reversible.
