IHP 310 Milestone One Guidelines and Rubric
Overview: Your final project for this course will be a patient record analysis. You will apply the knowledge of anatomy, physiology, and pharmacology that you
have developed during this course in a thorough review of existing patient information in the Final Project Patient File. Specifically, you will review a patient’s
history and a discharge chart from a recent physician visit, explaining the reasons behind diagnosis (or diagnoses) based on documented symptoms, citing any
inconsistencies or concerns, and discussing the potential and current treatments, all in preparation for your future coding practices.
For this milestone, you will review the patient history file and discuss what it tells you. Discriminating between signs and symptoms, primary diagnoses,
secondary diagnoses, and differential diagnoses, discuss what the findings are.
Specifically, the following critical elements must be addressed:
I. Patient History Analysis
a) Summarize the patient history, explaining key patient demographics and family history that could be risk factors for common diseases.
b) Identify the past diagnosis (or diagnoses, if more than one exists in the file) and explain how the diagnosis was made. Specifically, what tests
were done?
c) Discuss the symptoms the patient showed according to the file. Why and how did these symptoms lead the doctors to order certain tests?
d) What alternate diagnosis (or diagnoses) could these symptoms have indicated? Explain using evidence-based resources to support your
conclusions.
e) Using supportive details from peer-reviewed resources, explain the pathophysiology of the diagnosis. In other words, how does the diagnosed
disease develop and progress in the body?
f) Identify the past prescribed medications the patient is taking and explain the purposes of their larger pharmacological groupings.
g) Explain what symptoms the specific medications are meant to treat, using resources to support your claims about the impact of the medication
on the symptoms.
h) Illustrate how these medications impact the body and its functions. Use examples to support your explanations.
Rubric
Guidelines for Submission: This milestone should be at least 2 pages in length and submitted as a Word document. All sources should be in APA format.
Critical Elements
Proficient (100%)
Needs Improvement (75%)
Not Evident (0%)
Value
Patient History Analysis:
Patient History
Summarizes the patient history,
accurately explaining key patient
demographics and family history details
that could be risk factors for common
diseases
Summarizes the patient history, but
with gaps or inaccuracies regarding key
demographics and family history details
that could be risk factors for common
disease
Does not summarize the patient history 12
Patient History Analysis:
Past Diagnosis
Explains how the past diagnosis was
determined with specific detail
regarding diagnostic tests
Explains how the past diagnosis was
determined, but lacks specific detail
regarding diagnostic tests
Does not explain how the past diagnosis
was determined
12
Patient History Analysis:
Symptoms
Discusses the symptoms recorded in the
patient history in terms of how and why
those symptoms led the doctor to the
determined diagnosis
Discusses the symptoms recorded in the
patient file in terms of how and why
they led the doctor to the determined
diagnosis, but with gaps in detail or
accuracy
Does not discuss how and why the
symptoms led the doctor to the
determined diagnosis
12
Patient History Analysis:
Alternate Diagnosis
Identifies a logical alternate diagnosis
(or diagnoses) that could have caused
the recorded symptoms, with evidence-
based support
Identifies an alternate diagnosis (or
diagnoses) that could have caused the
recorded symptoms, but with gaps in
logic or evidence-based support
Does not identify an alternate diagnosis
that could have caused the recorded
symptoms
12
Patient History Analysis:
Pathophysiology
Accurately explains the pathophysiology
of the diagnosis with supportive detail
from peer-reviewed resources
Explains the pathophysiology of the
diagnosis, but with gaps in accuracy or
supportive detail from peer-reviewed
resources
Does not explain the pathophysiology of
the diagnosis
12
Patient History Analysis:
Pharmacological Grouping
Accurately identifies the past prescribed
medications, explaining the purposes of
their larger pharmacological groupings
Identifies the past prescribed
medications, explaining the purposes of
their larger pharmacological groupings,
but with gaps in accuracy or necessary
detail
Does not identify the past prescribed
medications, explaining the purposes of
their larger pharmacological groupings
12
Patient History Analysis:
Specific Medications
Accurately explains the uses for and
impact of the prescribed medications on
specific symptoms, with resource
support
Explains the uses for and impact of the
prescribed medications on specific
symptoms, but lacks resource support
or accuracy
Does not explain the uses for and impact
of the prescribed medications on specific
symptoms
12
Patient History Analysis:
Impact
Accurately illustrates how the specific
medications impact the human body
and its functions, with specific examples
for support
Explains how the specific medications
impact the human body and its
functions, but lacks accuracy or specific
examples for support
Does not explain how the specific
medications impact the body and its
functions
12
Articulation of Response Submission has no major errors related
to citations, grammar, spelling, syntax,
or organization
Submission has major errors related to
citations, grammar, spelling, syntax, or
organization that negatively impact
readability and articulation of main
ideas
Submission has critical errors related to
citations, grammar, spelling, syntax, or
organization that prevent understanding of
ideas
4
Total 100%
