iHuman Documentation Guide

iHuman Documentation Guide

This guide serves as assistance for completing documentation within the iHuman Virtual Patient Encounter. It is essential to note that all documentation pertaining to the patient visit must be entered into the iHuman platform.

Electronic Medical Record (EMR) Documentation

Utilize the Patient Record to document relevant information concerning the patient’s history and physical examination. The Patient Record can be accessed and updated at any time during your assignment by clicking on the “Show Patient Record” button. To return to your patient, click the “Hide Patient Record” button in the iHuman Documentation Guide.

EMR Tips

– Chief Complaint (CC): This should be a concise statement identifying why the patient is seeking medical attention, in the patient’s own words. For example, “headache,” not “bad headache for 3 days.” If the patient has multiple complaints, differentiate the CC from associated symptoms. For instance, if the patient presents with cough and sore throat, specify which is the CC and which is an associated symptom.

Advanced Physiology and Pathophysiology

– OLD CARTS: Utilize OLD CARTS to document the history of the present illness (HPI).

– Ensure that you include all relevant past medical history, medications, and allergies. Describe the patient’s reaction/response to each allergen.

– Document the dosage, frequency, duration of use, and reason for using each medication, including over-the-counter (OTC) or homeopathic products.

– Restrict preventive health, family, and social history to findings pertinent to the HPI. Social history may encompass occupation, major hobbies, family status, tobacco and alcohol use, and other relevant data such as health-promoting behaviors like consistent seat belt use or functional smoke detectors in the house.

– Family history should include any illnesses with possible genetic predisposition, contagious or chronic diseases. Also, include the reason for the death of any deceased first-degree relatives (e.g., parents, grandparents, siblings, children, and grandchildren if pertinent).

– During the review of systems (ROS), address all body systems that may help in diagnosing the patient’s condition. Focus on positive and negative findings that are pertinent to the focused health history. Describe the findings rather than using “Within Normal Limits (WNL).”

– Document physical examination findings obtained through inspection, palpation, auscultation, and percussion under the physical exam section. Limit physical exam documentation to findings relevant to your focused assessment based on the chief complaint. If you cannot assess a specific body system, indicate “Unable to assess.” Clearly document pertinent positive and negative assessment findings.

Key Findings

Add key findings at any point during your history or physical exam by clicking the “+” sign. You can organize key findings using the up and down arrows. Further organization of key findings will occur in the Assessment step.

Problem Statement

Problem Statement: Create a problem statement using professional language. Include pertinent demographic data, a concise description of the HPI, other relevant subjective findings, and a brief summary of pertinent objective findings. Summarize the data collected and documented in your EMR. Note that the problem statement has a 155-word limit.

Management Plan

Using the provided expert diagnosis, formulate a comprehensive treatment plan using professional language. Use headings to address all five components of the comprehensive treatment plan. If you do not intend to order an intervention for a specific part of the treatment plan, state “None at this time,” but ensure you address each area. Providing a rationale and evidence-based in-text citations for each intervention is essential. Include at least one appropriate, evidence-based scholarly source to support your decisions.

Management Plan Tips:

– Diagnostic tests:

Include the appropriate tests provided within the iHuman case. Do not include test results. Rationale or citation for diagnostic tests is not required.

– Medications/treatments:

List medications/treatments, including OTC drugs you will order and indicate “continue meds” if applicable. Provide evidence-based treatment recommendations and explain the rationale for your decisions. Support your choices with scholarly literature and in-text citations.

– Consults/referrals:

Offer a list of suitable referrals, along with a rationale for each, supported by scholarly literature and in-text citations.

– Client education:

Document appropriate client education, including a rationale and support from scholarly literature with in-text citations.

– Follow-up:

Specify when the patient should return and provide detailed symptomatology indicating if the patient should return sooner than scheduled or seek attention elsewhere.

– Ensure you provide the full reference for all in-text citations used. Note that italics cannot be applied to the title of your journal article within iHuman documentation.

– You only need 1-2 Evidence-Based Practice (EBP) references for the SOAP note. Each reference should support your selection of interventions and guide clinical decision-making. The most suitable references are national guidelines or treatment protocols.

– If you prefer, complete the SOAP note in a Word document and copy/paste it into the iHuman Plan tab when finished.