Focused Health History
Complete a focused health history. Scores are automatically calculated within the iHuman platform when the health history is submitted.
Focused Physical Exam
Complete a focused physical exam. Scores are automatically calculated within the iHuman platform when the health history is submitted.
EHR Documentation (Subjective Data): Document the history of present illness (HPI) and focused review of systems (ROS). Documentation must be:
accurate
detailed
written using professional terminology
pertinent to the chief complaint
includes subjective findings only
EHR Documentation (Objective Data): Document physical exam findings. Documentation must be:
accurate
detailed
written using professional terminology
pertinent to the chief complaint
include objective findings only
Key Findings/Most Significant Active Problem: Document key findings from the history and physical exam in the Assessment tab of the case.
Identify the most significant active problem (MSAP) and the relation of other key findings to the MSAP
Problem Statement: Document a brief, accurate problem statement using professional language. Include the following components:
name or initials, age
chief complaint
positive and negative subjective findings
positive and negative objective findings
Management Plan: Use the expert diagnosis provided to create a pertinent comprehensive evidence-based management plan. If a specific component of the management plan is not warranted (i.e., no referrals are appropriate for the virtual patient) document that no intervention is warranted. Include the following components:
diagnostic tests
medications: Type a specific prescription for each medication, including over-the-counter medications
suggested consults/referrals
client education
follow-up, including time interval and specific symptomatology to prompt a sooner return
Provide rationales for each intervention and cite at least one relevant scholarly source as defined by program expectations
Click "Submit" once the case is complete. Use this guide to download the Performance Overview ReportLinks to an external site..
Reflection: Download this worksheetLinks to an external site.. Type your reflection responses on the worksheet and upload the worksheet including the title page to the designated drop box for the assignment in Canvas.
Assess your ability to gather information on your client within the iHuman Virtual Patient Encounter.
Use the iHuman score sheet to review your results for the focused health history and focused physical exam. How did you perform?
What did you find easy or difficult about navigating through focused health history and focused physical exam sections of the case?
Describe two strategies to improve your performance in the next Virtual Patient Encounter.
Assess your performance in documenting your findings on the electronic health record (EHR).
What did you find easy or difficult about navigating through the documentation of history and physical within the system?
Did you document all required components in the case?
Describe two strategies to improve your performance in the next Virtual Patient Encounter.
Assess your performance in determining key findings and identifying the most significant active problem.
What did you find easy or difficult about navigating through the key findings and organization section of the case?
How did your key findings and MSAP compare with the expert’s response provided?
Describe one strategy to improve your performance in the next Virtual Patient Encounter.
Assess your performance in creating and documenting a problem statement within the iHuman case.
What did you find easy or difficult about creating the problem statement?
How did your problem statement compare with the expert’s response provided?
Describe two strategies to improve your performance in the next Virtual Patient Encounter.
Assess your performance in creating and documenting a management plan within the iHuman case.
What did you find easy or difficult about creating the management plan?
How did your management plan compare with the expert’s response provided?
Describe two strategies to improve your performance in the next Virtual Patient Encounter.
Submission
Submit both the Performance Overview Report of your last submitted attempt and the reflection document to the Week 2 dropbox. The Performance Overview Report submitted to dropbox will be graded.
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