NR 509 Week 3 Assignment
NR 509 Week 3 Assignment: iHuman Virtual Patient Encounter – HEENT Assessment
- Assigned iHuman Case & Reflection – Amanda a Wheaton
- Assigned iHuman Case & Reflection – Jenna a James
I. Focused Health History
- Complete a focused health history. Scores are automatically calculated within the iHuman platform when the health history is submitted.
II. Focused Physical Exam
- Complete a focused physical exam. Scores are automatically calculated within the iHuman platform when the health history is submitted.
III. 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
IV. 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
V. 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
VI. 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
VII. 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: write 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
- 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 Report Links to an external site.
VIII. Reflection: Address the following question – How would the management plan change for the Week 3 virtual patient if the patient were uninsured? Include the following components:
- write 150-300 words in a Microsoft Word document
- demonstrate clinical judgment appropriate to the virtual patient scenario
- cite at least one relevant scholarly source as defined by program expectations
- communicate with minimal errors in English grammar, spelling, syntax, and punctuation
