Description
NR509 Week 3 iHuman: Jenna James
Patient history, physical assessment, problem statement, management plan, and EHR.
CASE PLAY INSTRUCTIONS AND HELP
History:
- You may ask up to 120 questions but must determine relevant questions. Questions should be focused on the present illness and associated body systems. More questions do not earn more credit.
- All documentation MUST be completed in the Electronic Health Record (EHR) within the iHuman Virtual Patient
Encounter. - Findings do not auto-populate in the EHR.
- Document information in the appropriate EHR sections of the patient history and enter abnormal findings under Key
Findings. - Document subjective information ONLY in the history.
- Suggested approach:
- Start by asking two open-ended questions: “How can I help you today?” and “Any other symptoms or concerns?”
- Next, obtain an HPI. Practice using the OLDCARTS method of documenting the HPI.
- Obtain previous medical history, family history, social history, and review of systems. Document as appropriate within the EHR in the platform.
Physical Exam:
• Open and view the patient’s record to receive credit for obtaining vital signs.
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HPI: Constitutional Complaints |
How can I help you today? |
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HPI: Other Complaints (A- H) HPI: Other Complaints (I – Z) |
Do you have any other symptoms or concerns we should discuss? |
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What symptom is the most distressing for you? |
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HPI: Pain Complaints (A – H) |
Has anyone else you know developed these symptoms? |
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HPI: Pain Complaints (I – Z) |
Tell me how that makes you feel. |
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HPI: Psychological Complaints |
How does this affect your life? |
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HPI: Sensation & Movement |
What is your name? |
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Complaints |
How would you like to be addressed? |
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Past Medical History (PMH) |
Where are you? |
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Family Medical History (FH) |
What time is it? |
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Social Hx (SH) |
What happened? |
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Review of Systems (ROS) |
Is there anything I can do for you right now?……………………………………………$25 |
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