NR 509 Week 2 iHuman Reflection Worksheet
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frameworks are significantly more accurate in selecting appropriate exams and forming differential diagnoses, even in unpredictable virtual case scenarios (Sanky et al., 2022). This approach will help me improve my performance in future encounters. B. Assess your performance in documenting your findings on the electronic health record (EHR). 1. What did you find easy or difficult about navigating through the documentation of the history and physical within the system? I found it difficult to document in this section because I wasn’t always sure which wording or phrasing to use when recording findings. For example, in the Review of Systems (ROS), I struggled with how to properly express what the patient reported. I later realized that I should use phrases like “patient denies” for symptoms the patient did not experience, but I often used the term “negative,” which may not be appropriate in that context. This made me unsure if my documentation was clear and clinically accurate. 2. Did you document all required components in the case? Yes, I documented all required components including the HPI, ROS, physical exam findings, medication use, and family/social history. 3. Describe one strategy to improve your performance in the next Virtual Patient Encounter. One effective strategy to improve my performance is to use standardized medical documentation templates and language guides before and during the encounter. These tools help ensure that I use clear, consistent, and clinically appropriate phrasing, especially for sections like the Review of Systems (ROS) and physical exam findings. For example, using phrases such as “patient denies” instead of “negative” to describe symptoms the patient does not have improves clarity and professionalism in documentation. Implementing structured and standardized documentation significantly improved the quality of electronic health record (EHR) notes in outpatient care (Ebbers et al., 2022). 0320 RB/KK 3. Describe one strategy to improve your performance in the next Virtual Patient Encounter. To improve, I will practice writing problem statements using a structured format like SBAR (Situation, Background, Assessment, Recommendation) or the SOAP note (Subjective, Objective, Assessment, Plan). Structured clinical documentation frameworks improve students’ ability to create clear, concise, and clinically relevant problem statements (Feldman et al., 2023). E. Assess your performance in creating and documenting a management plan within the iHuman case. 1. What did you find easy or difficult about creating the management plan? I feel this case is more straightforward and the management plan is basically based on flu symptoms given the flu test is positive. Therefore, it was not that difficult create the interventions for flu management, but it is difficult to have evidence-based practice to support these interventions. 2. How did your management plan compare with the expert’s response provided? My management plan addressed key areas including diagnostics, medications, patient education, and follow-up. However, compared to the expert’s response, mine was less detailed and not as thoroughly supported by current evidence-based guidelines. The expert’s plan provided more comprehensive explanations and stronger references to evidence-based practices, which enhanced the clarity and clinical appropriateness of their recommendations. 3. Describe one
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