NR 511 Final Exam Questions with Complete Solutions| Graded A+

Define Diagnostic Reasoning - To solve problems, to promote health, and to screen for disease or illness. All require a sensitivity to complex stories, to contextual factors, and to sense of probability and uncertainty. Can be seen as a kind of critical thinking. Discuss and identify subjective data - reports, complaints of , replies to provider questions, includes ROS, CC, HPI Discuss and identify objective data - what you can see, hear, or feel as part of a clinical exam. Also includes laboratory data and test results. Discuss and identify the components of and HPI - OLDCARTS Onset of CC, Location of CC, Duration of CC, Characteristics of CC, Aggravating factors of CC, Relieving factors of CC, Treatment of CC, Severity of CC Medical coding - the use of codes to communicate with payers about which procedures were performed and why Medical billing - the process of submitting and following up on claims made to a payer in order to receive payment for medical services rendered by a healthcare provider 2 Coding Classification systems that are currently used in the US healthcare system - CPT-recognized universally and provide logical means to be able to track healthcare data, trends, and outcomes. ICD-10-shorthand for the patient's diagnosis, which are used to provide the payer information on the necessity of the visit or procedures performed. Specificity - referring to the ability of the test to correctly detect a specific condition Sensitivity - a test with a few false negatives Predictive value - likelihood the patient actually has a condition and is in part dependent upon the prevalence of the condition in the population Elements needed when developing a plan - acknowledge the list, negotiate what to cover, be honest, make a follow up Components of medical decision making (E&M) coding - history, physical, medical decision making E&M coding requires a medical decision maker a way of quantifying the complexity of the thinking that is required for the visit-complexity=risk, data, diagnosis MDM score gives credit for the excess work involved in management of a more complex patient Correctly order the E&M office visits based on complexity from least to most complex - Discuss a minimum of three purposes of the written H&P in relation to the importance of documentation - Important reference document that gives concise information about a patient's history and exam finding Outlines a plan for addressing the issues that prompted the visit. This information should be presented in a logical fashion that prominently features all data immediately relevant to the patient's condition Means of communicating information to all providers who are involved in the care of a particular patient Important medical-legal document Essential in order to accurately code and bill for services Accurately document why every procedure code must have a corresponding diagnosis code - every procedure code needs a diagnosis to explain the necessity whether the code represents an actual procedure performed or a nonprocedural encounter like an office visit Correctly identify a patient as a new patient given the historical information - one who has not received professional services from a provider from the same group practice within the past 3 year. Correctly identify a patient as an established patient given the historical information - one who has received professional service from a provider of the office within the past 3 years Identify the 3 components required in determining an outpatient, office visit E&M code - place of service-inpatient, outpatient type of service-consultation, office visit, hospital admission patient status-new-has not received professional service from a provider in the same practice within the past 3 year established-has received professional care within 3 year Explain what a well rounded clinical experience is - Includes both children from birth through young adult visits for well child and acute visits, as well as wellness, acute, and routine visits of adults What is the maximum number of hours that can be spent rounding in a facility - 25% State 9 things that must be documented when inputting data into clinical encounters - Date of service, gender and ethnicity, tests performed or orderd, visit E&M code, chief concerns, diagnosis, age, procedures, level of involvement