iHuman Documentation Guide
Use this guide to assist you in completing documentation within the iHuman Virtual Patient Encounter. All documentation related to the patient visit must be entered into the iHuman platform.
EMR Documentation
Utilize the Patient Record to document relevant information regarding the patient’s history and physical examination. You can access and update the patient record at any time during your assignment by clicking on the Show Patient Record button. Click the Hide Patient Record button in the iHuman Documentation Guide to return to your patient.
iHuman EMR Tips
– Chief Complaint (CC): Provide a concise statement in the patient’s own words, identifying why they are here. For example, “headache” rather than “bad headache for 3 days.” In cases where the patient has multiple complaints, distinguish the CC from associated symptoms.
– Use OLD CARTS to document the history of the present illness (HPI).
– Include all relevant past medical history, medications, and allergies.
– Specify the reaction/response to each allergen.
– Include details such as dosage, frequency, duration of use, and the reason for using each medication. Also, mention any over-the-counter (OTC) or homeopathic products.
– Limit 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 information. Include health promotion practices, such as consistent seat belt use or functional smoke detectors.
– Family history should cover illnesses with potential genetic predisposition, contagious or chronic illnesses. Include the cause of death for deceased first-degree relatives, such as parents, grandparents, siblings, children, and relevant grandchildren.
– In the Review of Systems (ROS), address all body systems that may help determine a differential diagnosis. Focus on positive and negative findings relevant to the focused health history. Describe the findings rather than using the abbreviation WNL.
– Document physical examination findings obtained through inspection, palpation, auscultation, and percussion under the physical exam section. Limit the documentation to findings pertinent to the focused assessment based on the chief complaint. If unable to assess a relevant body system, indicate “Unable to assess.” Clearly describe pertinent positive and negative assessment findings.
Key Findings
Add key findings during the history or physical exam by clicking the + sign. You can organize the key findings using the up and down arrows. Further organization of key findings will be done in the Assessment step.
Problem Statement
Problem Statement: Create a problem statement using professional language. Include pertinent demographic data, a brief description of the HPI, other relevant subjective findings, and a concise description of pertinent objective findings. Summarize the data collected and documented in the EMR. Note that the problem statement has a 155-word limit. A sample problem statement is provided in the iHuman Documentation Guide.
Management Plan
Based on the expert diagnosis provided, develop a comprehensive treatment plan using professional language. Use headings to address all five parts of the comprehensive treatment plan. If no intervention is planned for a specific part, state “None at this time,” but ensure that each area is addressed. Provide a rationale for each intervention, supported by evidence-based in-text citations. Include at least one appropriate, evidence-based, scholarly source to support your decisions. A sample management plan is presented in the iHuman Documentation Guide.
Management Plan Tips:
– Diagnostic tests: Include the ordered tests in your management plan without providing results. Rationale or citations for diagnostic tests are not required.
– Medications/treatments: List medications/treatments, including any OTC drugs, and indicate “continue meds” if relevant. Offer evidence-based treatment recommendations, explaining the rationale for your decisions and supporting them with scholarly literature through in-text citations.
– Consults/referrals: Provide a list of appropriate referrals, including a rationale for each and supporting them with scholarly literature through in-text citations.
– Client education: Document appropriate client education, providing a rationale and supporting it with scholarly literature through in-text citations.
– Follow-up: Indicate when the patient should return and provide detailed symptomatology to determine if the patient should return sooner than scheduled or seek attention elsewhere.
– Include the full references for all in-text citations used. Note that italics for journal article titles are not available in iHuman documentation.
– For the SOAP note, include 1-2 evidence-based practice (EBP) references that support your selection of interventions and guide clinical decision making. National guidelines or treatment protocols are recommended as the best references.
– You may choose to complete the SOAP note in a Word document and copy/paste it into the iHuman Plan tab when it is complete.