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NR511 NR 511 Final Exam Latest Differential Diagnosis Primary Care Practicum Chamberlain week 8
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NR511 / NR 511 Final Exam (Latest 2023 / 2024): Differential Diagnosis & Primary Care Practicum - Chamberlain week 8 Define Diagnostic Reasoning Discuss and identify subjective data Discuss and identify objective data Discuss and identify the components of and HPI Medical coding Medical billi...

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  • February 28, 2024
  • 42
  • 2023/2024
  • Exam (elaborations)
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NR511 / NR 511 Final Exam (Latest 2023 /
2024): Differential Diagnosis & Primary Care
Practicum - Chamberlain week 8

1). Define diagnostic reasoning

 Ans: 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.


2). Discuss and identify subjective data

 Ans: reports, complaints of , replies to provider questions, includes ROS, CC, HPI


3). Discuss and identify objective data

 Ans: what you can see, hear, or feel as part of a clinical exam. Also includes
laboratory data and test results.


4). Discuss and identify the components of and hpi

 Ans: 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


5). Medical coding

 Ans: the use of codes to communicate with payers about which procedures were
performed and why


6). Medical billing

 Ans: 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




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, 7). 2 coding classification systems that are currently used in the us healthcare system

 Ans: 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.


8). Specificity

 Ans: referring to the ability of the test to correctly detect a specific condition


9). Sensitivity

 Ans: a test with a few false negatives


10). Predictive value

 Ans: likelihood the patient actually has a condition and is in part dependent upon the
prevalence of the condition in the population


11). Elements needed when developing a plan

 Ans: acknowledge the list, negotiate what to cover, be honest, make a follow up


12). Components of medical decision making (e&m) coding

 Ans: 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


13). Correctly order the e&m office visits based on complexity from least to most complex

 Ans: 99212-99214


14).



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, Discuss a minimum of three purposes of the written h&p in relation to the importance of
documentation

 Ans: 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


15). Accurately document why every procedure code must have a corresponding diagnosis
code

 Ans: 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


16). Correctly identify a patient as a new patient given the historical information

 Ans: one who has not received professional services from a provider from the same
group practice within the past 3 year.


17). Correctly identify a patient as an established patient given the historical information

 Ans: one who has received professional service from a provider of the office within
the past 3 years


18). Identify the 3 components required in determining an outpatient, office visit e&m code

 Ans: 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


19). Explain what a well rounded clinical experience is

 Ans: 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




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, 20). What is the maximum number of hours that can be spent rounding in a facility

 Ans: <25%


21). State 9 things that must be documented when inputting data into clinical encounters

 Ans: Date of service, gender and ethnicity, tests performed or orderd, visit E&M code,
chief concerns, diagnosis, age, procedures, level of involvement


22). Identify and explain each part of the acronym snapps

 Ans: S-summarize, N-narrow, A-analyze, P-probe, P-plan-S-self-directing learning


23). Identify the most common type of pathogen responsible for acute gastroenteritis

 Ans: viral: norovirus-adults
rotovirus-0-2yrs


24). Assessing for prior antibiotic use is a critical part of the history in patients with presenting
with _______________ due to_________________

 Ans: Diarrhea/CDiff


25). Irritable bowel syndrome

 Ans: disorder of the bowel function not from anatomic abnormality--constipation,
diarrhea, bloating, urgency w/diarrhea
+s/s--result from disordered sensations or abnormal function of the small and large
bowel
NOT associated with serious medical conditions, IBD, CA


26). Inflammatory bowel disorder

 Ans: chronic immunologic disease that manifests in intestinal inflammation
Ulcerative colitis
crohn's disease


27). Two common inflammatory bowel diseases

 Ans: Ulcerative colitis-mucosal surface of the colon is inflamed and ultimately results
in frability, erosions, and bleeding--most common in recto-sigmoid colon. Can involve



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