HUMAN PATIENTS CASE STUDY: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT

I-HUMAN PATIENTS CASE STUDY: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT

Throughout this course, you have reviewed Learning Resources on various body systems and completed i-Human Patients Assignments for particular systems. For this i-Human Patients Assignment, you connect the knowledge and skills you gained from each individual assessment to perform a comprehensive head-to-toe physical examination.

Note: You must pass the Week 9 Assignment to pass the course.

History: Complete an appropriate health history. (Scores are automatically calculated in the i-Human platform.),

This criterion is linked to a Learning Outcome Physical Exam: Complete an appropriate physical exam. (Scores are automatically calculated in the i-Human platform.)

EMR Documentation Chief Complaint and History of Present Illness 5 criteria using OLDCARTS: 1.) Complete; 2.) Accurate; 3.) Written in Professional Language; 4.) Pertinent to the Chief Complaint; 5.) Includes Subjective findings only (Evidence of Academic Integrity Issues will result in a grade of 0.)

EMR Documentation Subjective Data Document Current Medications, PMH, Allergies, Family History, Social History, Preventive Health, Review of Systems 5 criteria: 1.) Complete; 2.) Accurate; 3.) Written in Professional Language; 4.) Pertinent to the Chief Complaint; 5.) Includes Subjective findings only (Evidence of Academic Integrity Issues will result in a grade of 0.)

EMR Documentation Objective Data Document Physical Exam Findings: 5 criteria: 1.) Complete; 2.) Accurate; 3.) Written in Professional Language; 4.) Pertinent to the Chief Complaint; 5.) Includes Objective findings only (Evidence of Academic Integrity Issues will result in a grade of 0.)

Key Findings: Organize the key findings with the most important first and least important last. (Evidence of Academic Integrity Issues will result in a grade of 0.)

Problem Statement: Document a brief and accurate problem statement using professional language that includes the following: 1.) Name or initials, age; 2.) Chief complaint; 3.) Positive and negative subjective findings; 4.) Positive and negative objective f indings. (Evidence of Academic Integrity Issues will result in a grade of 0.)

Management Plan: Use the expert diagnosis provided to create a pertinent, comprehensive, evidenced-based management plan. Address the following criteria in the

plan: 1.) Diagnostic tests; 2.) Medications (write out a complete order, even for OTC meds); 3.) Suggested consults/referrals; 4.) Patient education; 5.) Follow-up, including time interval and specific symptoms to prompt a return visit sooner; 6.) Provide rationales for each intervention and include references to support your plan. Clinical practice guidelines should be utilized as applicable. (Evidence of Academic Integrity Issues will result in a grade of 0.)