i-Human Case Week #9 26 y/o 5′ 6″ (168 cm) 122.0 lb (55.5 kg) Reason for encounter More frequent severe headaches Location Outpatient clinic

It is so IMPORTANT to complete each section of the I-human. A lot of students missed the EMR section (Electronic medical Record). This is where you will document your subjective and objective data. Some students posted this documentation under the Management and plan section (you may have learned this in the I-human student overview) but I would not suggest that at all. If you post it there you MUST also post in the EMR section as that is where this information belongs 

Utilize your resources. Use your clinical guide to documentation text as a guide for documentation. 

Some of main issues I found while grading these assignments are the following.

• Not following the grading rubric
• Loss of points because the EMR was left blank
• Management and plan: follow the grading rubric and make sure to use references to support your plan. You will also need to add rationales for your interventions. If you do not document, it then it was not done. 
• ROS: provide detailed documentation (state what the pt c/o and denies). 
• Physical Exam (PE) Do not use WNL or no abnormal findings– this does not demonstrate critical thinking skills in regard to documentation. document the normal and abnormal findings. 
• HPI: provide detailed documentation elaborating on the reason for the visit using old carts or locates
• EMR: the encounter reason: is the same as the chief complaint: this should only be a few words
• EMR section: Complete all sections

    EHR Documentation Tips

• Chief complaint (CC) is a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”. Sometimes a patient has more than one complaint.  For example, if the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom
• Use OLD CARTS to document history of present illness (HPI)
• Be sure to include all past medical history, medications, and allergies.
• Include reaction/response to each allergen.
• Include dosage, frequency, length of time used and reason for use for each medication; also include OTC or homeopathic products.
• Social history may include but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as seat belt use all the time or functional smoke detectors in the house, etc.

• Family history: parents, grandparents, siblings, and children. Include grandchildren if pertinent.
• In your review of systems (ROS), address all body systems that may help rule in or out a differential diagnosis. State what the patient tells you (pt c/o or denies);. If a system is not reviewed: state not reviewed.
• Provide detailed documentation Information that should be gathered during the physical examination by inspection, palpation, auscultation, and percussion should be documented under physical exam. Limit physical exam documentation to findings pertinent to your focused assessment based on the chief complaint. If unable to assess a pertinent body system, write “Unable to assess. Separate the assessment findings accordingly and be detailed. Describe findings; do not use WNL. Document detailed normal and abnormal findings. (Refer to your Clinical Guide to Documentation Text as well).

Key Findings

As you are working on the case you can add key findings and you organize them based on the most important.

When coming up with the key findings consider the most important symptoms that would be pertinent in diagnosing the patient based on the final diagnoses/working diagnoses provided in I-human.

Problem statement

• Use the information you have collected from the HER and document your problem statement. Consider the pertinent subjective and objective data findings, demographic information (name, age etc),

Management and plan

• This should include the following: diagnostic test and labs that are ordered. Medications (RX and OTC), Patient education, Referrals (if none- state that) and follow-up (this should include a realistic time frame) and also discuss when the patient should seek emergent care (document signs and symptoms that would warrant follow-up).

 I hope that you find this helpful.

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• Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). Elsevier Mosby. 
  • Chapter 7, “Mental Status” 
    This chapter revolves around the mental status evaluation of an individual’s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms. 
  • Chapter 23, “Neurologic System” 
    The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings. 
• Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). F. A. Davis Company. 
  • Chapter 2, “The Comprehensive History and Ph