26 year old female with sever headache behind left eye occurs monthly worse last couple weeks started 10 years ago, Mother has a chronic headache. I need management plane
This criterion is linked to a Learning OutcomeHistory: Complete an appropriate health history. (Scores are automatically calculated in the i-Human platform.)
20 pts
Excellent
Achieves a score of 90–100%
15 pts
Good
Achieves a score of 80–89%
10 pts
Fair
Achieves a score of 70–79%
5 pts
Poor
Achieves a score of 60–69%
0 pts
Unsatisfactory
Achieves a score of 59% or below
20 pts
This criterion is linked to a Learning OutcomePhysical Exam: Complete an appropriate physical exam. (Scores are automatically calculated in the i-Human platform.)
20 pts
Excellent
Achieves a score of 90–100%
15 pts
Good
Achieves a score of 80–89%
10 pts
Fair
Achieves a score of 70–79%
5 pts
Poor
Achieves a score of 60–69%
0 pts
Unsatisfactory
Achieves a score of 59% or below
20 pts
This criterion is linked to a Learning OutcomeEMR 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.)
10 pts
Excellent
Complete HPI meeting all 5 criteria.
8 pts
Good
4 requirements are met.
6 pts
Fair
3 requirements are met.
4 pts
Poor
1–2 requirements are met.
0 pts
Unsatisfactory
No requirements are met.
10 pts
This criterion is linked to a Learning OutcomeEMR 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.)
10 pts
Excellent
Complete HPI meeting all 5 criteria.
8 pts
Good
4 requirements are met.
6 pts
Fair
3 requirements are met.
4 pts
Poor
1–2 requirements are met.
0 pts
Unsatisfactory
No requirements are met.
10 pts
This criterion is linked to a Learning OutcomeEMR 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.)
10 pts
Excellent
Complete HPI meeting all 5 criteria.
8 pts
Good
4 requirements are met.
6 pts
Fair
3 requirements are met.
4 pts
Poor
1–2 requirements are met.
0 pts
Unsatisfactory
No requirements are met.
10 pts
This criterion is linked to a Learning OutcomeKey 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.)
5 pts
Excellent
The key findings are complete and appropriately organized.
4 pts
Good
The key findings are complete but the organization is not correct.
3 pts
Fair
There are 1–2 key findings missing or organized inappropriately.
2 pts
Poor
There are 3 key findings missing and organization is incorrect.
0 pts
Unsatisfactory
There are more than 3 key findings missing and organization is incorrect.
5 pts
This criterion is linked to a Learning OutcomeProblem 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 findings. (Evidence of Academic Integrity Issues will result in a grade of 0.)
5 pts
Excellent
All requirements are met.
4 pts
Good
3 requirements are met.
3 pts
Fair
2 requirements are met.
2 pts
Poor
1 requirement is met.
0 pts
Unsatisfactory
No requirements are met.
5 pts
This criterion is linked to a Learning OutcomeManagement 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.)
15 pts
Excellent
All requirements are met.
13 pts
Good
5 requirements are met.
10 pts
Fair
4 requirements are met.
7 pts
Poor
1-3 requirements are met.
0 pts
Unsatisfactory
No requirements are met.
15 pts
This criterion is linked to a Learning OutcomeReferences and Format: Current APA citations for references in management plan. Use of clinical practice guidelines when applicable.
5 pts
Excellent
0–1 errors Clinical practice guidelines used when applicable.
4 pts
Good
2–3 errors Clinical practice guidelines used when applicable.
3 pts
Fair
4–5 errors Clinical practice guidelines not used when applicable.
2 pts
Poor
6–7 errors Clinical practice guidelines not used when applicable.
0 pts
Unsatisfactory
More than 7 errors; clinical practice guidelines not used when applicable.
5 pts
Total Points: 100