Exam (elaborations)
Nr 511 week 1 clinical preparedness exam
- Course
- NR511 (NR511NR511)
- Institution
- Chamberlain College Of Nursing
Nr 511 week 1 clinical preparedness exam
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,Nr 511 week 1 clinical preparedness exam
Week One
● 1.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 a sense
of probability and uncertainty.
-Diagnostic reasoning can be seen as a kind of critical thinking. Critical
thinking involves the process of questioning one’s thinking to determine if all
possible avenues have been explored and if the conclusions that are being
drawn are based on evidence. Diagnostic reasoning then includes a
systematic way of thinking that evaluates each new piece of data as it either
supports some diagnostic hypothesis or reduces the likelihood of others.
● 2.Identify subjective & objective data.
-Subjective:
-reports
-complains of
-tells you in response to your questions.
-Includes ROS, CC, and HPI
-Objective:
-what you can see, hear, or feel as part of your clinical exam.
-It also includes laboratory data and test results.
● 3.Identify the components of the HPI.
-O: Onset of CC
-L: Location of CC
-D: Duration of CC
-C: Characteristics of CC
-A: Aggravating factors for CC
-R: Relieving factors for CC
-T: Treatments tried for CC
-S: Severity of CC
● 4.Develop an appropriate differential.
-Differential diagnosis, or differential, is a list (single) of plausible
diagnoses (plural) that fit the historical and clinical presentation of your
patient in order of priority.
-This is different than the problem list, which is a list that includes all of the
active medical problems for the patient.
● 5.Accurately describe 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.
● 6.Identify the three components required in determining an outpatient,
office visit E&M code.
-Place of service
-Inpatient
-Outpatient
,Nr 511 week 1 clinical preparedness exam
-Type of service
-Consolations
-Office visit
-Hospital admission
-Patient status
-New patient: one who has not received professional service
from a provider from the same group practice within
the past 3 years.
-Established patient of your practice: has received professional
● 7.Describe the differences between medical billing and medical coding.
-Medical coding: is the use of codes to communicate with payers about
which procedures were performed and why.
-Medical billing: is the process of submitting and following up on claims
made to a payer to receive payment for medical services rendered by a
healthcare provider.
● 8.Compare and contrast the two coding classification systems that are
currently used in the U.S. healthcare system.
-The CPT system offers the official procedural coding rules and guidelines
required when reporting medical services and procedures performed by
physician and non- physician providers.
-CPT codes are recognized universally and provide a logical means to be able
to track healthcare data, trends, and outcomes.
-ICD-10 codes are shorthand for the patient’s diagnoses, which are used to
provide the payer information on the necessity of the visit or procedure
performed.
● 9.Discuss how specificity, sensitivity, and predictive value contribute to the
usefulness of diagnostic data.
-Specificity of a test, we are referring to the ability of the test to correctly
detect a specific condition.
-Predictive value is the likelihood that the patient has the condition and is,
in part, dependent upon the prevalence of the condition in the population.
-When a test is very sensitive, we mean it has few false negatives.
● 10. Discuss the elements that need to be considered when developing a plan.
-Acknowledge the list
-Negotiate what to cover
-Be Honest
-Make a follow-up
● 11.Describe the components of medical decision making in E&M
coding.
- There are three key components that determine risk-based E&M
codes.
-History
-Physical
-Medical Decision Making (MDM) E&M coding requires a
medical decision maker
-Medical decision making is another way of quantifying the complexity of
the thinking that is required for the visit.
, Nr 511 week 1 clinical preparedness exam
-Complexity of a visit is based on three criteria:
-Risk
-Data
-Diagnosis
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