Complete the following components in the iHuman Virtual Patient Encounter for the required case addressing the head, eye, ear, nose, and throat (HEENT) system.
I. Focused Health History
i. Complete a focused health history. Scores are automatically calculated within the iHuman platform when the health history is submitted.
II. Focused Physical Exam
i. 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:
i. accurate
ii. detailed
iii. written using professional terminology
iv. pertinent to the chief complaint
v. includes subjective findings only
IV. EHR Documentation (Objective Data): Document physical exam findings. Documentation must be:
i. accurate
ii. detailed
iii. written using professional terminology
iv. pertinent to the chief complaint
v. 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.
i. 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:
i. name or initials, age
ii. chief complaint
iii. positive and negative subjective findings
iv. 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:
i. diagnostic tests
ii. medications: write a specific prescription for each medication, including over-the-counter medications
iii. suggested consults/referrals
iv. client education
v. follow-up, including time interval and specific symptomatology to prompt a sooner return
vi. cite at least one relevant scholarly source as defined by program expectations
vii. 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:
i. write 150-300 words in a Microsoft Word document
ii. demonstrate clinical judgment appropriate to the virtual patient scenario
iii. cite at least one relevant scholarly source as defined by program expectations
iv. communicate with minimal errors in English grammar, spelling, syntax, and punctuation