Description
NR509 Week 5 iHuman: Felipe Garcia
Case Instructions
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 (ER) within the Human 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.
- Click on appropriate physical exams of the present illness and associated body systems to determine findings for the patient.
- Document physical exam information in the EHR in the appropriate sections of the Physical Examination and enter abnormal findings under Key Findings. All documentation MUST be completed in the EHR within the Human Virtual Patient Encounter.
- Document objective information ONLY in the Physical Exam.
- Avoid ambiguous terms like “normal”. What is normal? Document what you found; interpret the findings later when you begin diagnosing the findings.
- If you did not assess a body system, document “Not assessed” rather than “Negative”. You do not want to infer findings that you did not assess inadvertently.
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HPI |
How can I help you today? |
I was recently at a health fair in my community where I had my blood pressure checked. The nurse told me that I should see a doctor because my pressure is too high. I think she said 170/92 or something like that. Do those numbers sound right? Anyhow, my wife was concerned and made the appointment. |
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HPI |
Do you have any other symptoms or concerns we should discuss? |
No, not really. |
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HPI |
When did your high blood pressure start? |
I don’t know. I remember some doctor years ago saying I should watch my diet because my pressure was a bit high… but I felt well and really didn’t pay him much attention. |
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HPI |
How severe is your high blood pressure? |
High enough that the nurse urged me to come in. |
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HPI |
Does anything make your high blood pressure better or worse? |
I don’t know. I haven’t been paying any attention……………………………….$25 |
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