1. Primary Diagnosis—10 points (all areas must be addressed)
a. What is the ICD-10 code (2 points):
b. What is your rationale for arriving at this primary diagnosis? You must integrate the pertinent finding and support your rationale with evidence-based literature (resources)(6 points)
c. Include CPT codes, and any procedural codes (such as nurse lab draws, vaccinations given, biopsies) (2 points):
2. Guidelines used to develop this primary diagnosis. 5 points
Here DO NOT write references.
In this section you need to write the clinical guidelines that you used to help you develop and create the plan for this diagnosis. For instance, for a kid with strep, students can follow the Centor Scoring for diagnosing strep and follow the IDSA guidelines for the management of strep.
1b and #2 should be two distinct answers.
3. Differential diagnoses (ddx)with rationale and resources. Minimum of 3-5 differentials (primary dx does not count as a differential). For well-child visit, if there are no other health issues, then differentials are not needed. 5 points
DDx#1-
DDx#2-
DDX #3-
4. Medications including OTC, dosage and education, additional ancillary
tests needed, referrals and follow up – 10 pts
a. Medications (2 points)-
b. Pt. education (2 points)- –
c. Additional Ancillary (2 points)-
d. Referrals (2 points)- –
e. Follow-ups (2 points)- –
5. Problem Statement – 5 pts (simply write see problem statement written in iHuman section. Please note that the problem statement that I grade is the one written in the “Problem Statement” section within the iHuman.
6. Social Determinants of Health to consider, Health Promotion and Pt risk factors – 5 pts
a. Social Determinants of Health (3 points)
b. Health Promotion (1 point)-
c. Pt. Risk Factors (1 point)—
REFERENCES (USE APA)
Must have 3 and must show that it is cited within your text. Please understand that references provide the information necessary for readers to identify and retrieve each work cited in the text. If your references are not cited within your text, then points will be deducted.
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