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EHR Documentation (Subjective Data)

  1. HEADACHE/NAUSEOUS
  1. EHR Documentation (Subjective Data): Document the history of present illness (HPI) and focused review of systems (ROS) including subjective data only Documentation must be:
    1. accurate
    2. detailed
    3. written using professional terminology
    4. pertinent to the chief complaint
  1. EHR Documentation (Objective Data): Document physical exam findings including objective findings only, Documentation must be:
    1. accurate
    2. detailed
    3. written using professional terminology
    4. pertinent to the chief complaint
  1. Key Findings/Most Significant Active Problem: Document key findings from the history and physical exam in the Assessment tab of the case.
    1. Identify the most significant active problem (MSAP) and the relation of other key findings to the MSAP
  1. Problem Statement: Document a brief, accurate problem statement using professional language. Include the following components:
    1. name or initials, age
    2. chief complaint
    3. positive and negative subjective findings
    4. positive and negative objective findings
  1. Management Plan: 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:
    1. diagnostic tests
    2. medications: type a specific prescription for each medication, including over-the-counter medications
    3. suggested consults/referrals
    4. client education
    5. follow-up, including time interval and specific symptomatology to prompt a sooner return
    6.  at least one relevant scholarly source and provide rationale for interventions as defined by program expectations
  • Reflection: Address the following question:  What are the “red flags” in this case? Based on your pertinent key findings, what is “the worst-case scenario”? What lessons did you learn from this case that you can apply to your future professional practice? Include the following components:
  1. type 150-300 words in a Microsoft Word document
  2. demonstrate clinical judgment appropriate to the virtual patient scenario
  3. cite at least one relevant scholarly source as defined by program expectations
  4. communicate with minimal errors in English grammar, spelling, syntax, and punctuation

CHIEF COMPLAINS

  • Patient alert and oriented x4
  • Temp 37.0(98.6F oral)
  • Pulse 80bpm regular normal
  •  B/P 124/82 normotensive, Norma RIGHT AND LEFT
  •  Respiration 14 regular unlabored
  • SPO2 97%
  • Patient is 22-year-old female
  • Height 5, 7(67cm)
  • Weight 118.0 LB (53.6kg)
  • BMI 18.4
  • Throbbing Headaches start yesterday- 1 day
  • Have has this current attack for more than a day/ for 30 hours
  • Felt it deep inside, precisely temporal and radiate all over r
  • Patient is getting it more often that usually lately every 4 to 6 weeks and it’s getting progressively worst
  • Rating 8/10 and happens more often
  • Start gradually and get progressively worst
  • Had same issue last year with an aura seeing flashes of light 20 minutes prior the attack
  • Patient currently had problem seeing certain direction due to this headache
  • No aura notices with this current attack
  • Patient taking 2 Tylenol q 4 hour for headache with no significant effect
  • Patient feels nauseated and loud noise bother her
  • Caffeine makes it worst
  • Has past history of headache stomach unsettled patient cannot eat
  • No trauma to head 
  • Patient on birth control pill
  • Patient Tylenol and multivitamin
  • Flu shot every year up to date and tetanus shot 5 years ago
  • Just feel stress and wish to have more sleep
  • Usually 2 types of headaches, one minor that goes away with Tylenol and another major that is resistant to Tylenol
  • Patient is experiencing major currently staying in the dark quite room helps
  • Sister and mother have had headache but most often and severe is sister              
  • Father 50years with high blood pressure issues
  • Mother 49
  • Sister 20 with frequent headache
  • Brother 15 is fine
  • Usually, to take alcohol 1 or 2 drink on weekend night or bar drink
  • Struggles with college weight gain due to junk food and lack of exercise
  • Childhood illness of chicken pox and mono resolved
  • Patient anxious to get better to write school work paper for final exam
  • Patient just broke up with boyfriend
  • She admitted been stress
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