Learner Support Center

Where do I document?

Last Updated: Feb 02, 2018 10:14AM EST

Documentation is a major part of any medical work, and it’s no different in Shadow Health. While in the exam room with a patient, you will have access to the Electronic Health Record, or EHR. Each assignment will have different sections within the EHR for you to view and use. Some have pre-filled information, such as records of medication, and some are meant for you to fill out. Each section in the EHR is easily accessed by clicking on it. When you’re done with that section, simply click the Back to Home button at the bottom of the EHR to take you back to the main EHR page (this does not leave the exam room).

Some sections in the EHR have boxes that you click to fill out, often choosing between Normal and Abnormal. When you select Abnormal, a small text box will appear so you can document any abnormalities. A text box will not appear when Normal is selected. Other sections of the EHR only contain open text boxes for you to input information you feel is necessary.

As you exit the exam room, you will first be prompted to review your documentation. This will show all saved documentation for you to ensure you didn’t miss any sections or information. If you are satisfied with your documentation, click Continue to proceed with the next step of the assignment. If you want to edit your documentation, click Back go back to the exam room and make any changes. Once you complete the assignment, you will have access to not only your documentation, but an example of model documentation that contains all relevant information for the patient, so you can compare your notes.

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