The Case Of Rosa Perez Assignment Paper

The Case Of Rosa Perez Assignment Paper

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NRNP 6541 I-Human
You will be completing the case of Rosa Perez. This is due Sunday 3/12
I-human tips and management plan template
Chief Complaint & HPI: You will type this in the EHR section of the case (NOT the problem statement). It can only be graded from this place! You will receive a zero for this section if not in the correct place.
This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. This is for subjective findings. Use LOCATES or OLDCARTS Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. Include any pertinent history information that might impact the differential diagnosis formulation. If the CC was “headache,” the LOCATES for the HPI would include the following information: The Case Of Rosa Perez Assignment Paper

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Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Any relevant family, medical or surgical history.
Physical exam – focused, unless physical. Look for medical issues if mental health problem. Work through the rest of the case, section by section. Review patient’s previous notes. Type out every section of the EHR.
• Management Plan Template– must include these headings
• Primary Diagnosis with ICD-10 code, rationale and resources. Include CPT codes, and any procedural codes, including nurse lab draws, vaccinations given, biopsies, etc…10 pts.
• Guidelines used to develop this primary diagnosis. 5 pts
• Differential diagnoses with rationale and resources. 3-5 Ddx required, unless well visit. 5 pts
• Medications including OTC, dosage and education, additional ancillary tests needed, referrals and follow up – 10 pts
• Problem Statement – 5 pts
• Social Determinants of Health to consider, Health Promotion and Pt risk factors – 5 pts
• Must use 3 scholarly references the course text may NOT be used as a reference. The references must be professional and not general patient education websites.
• Worth 40 points The Case Of Rosa Perez Assignment Paper