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NR511 Midterm Exam Study Guide Solutions

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NR511 Midterm Exam Study Guide Solutions Define diagnostic reasoning - ANSWER-Reflective thinking because the process involves 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. Seen as a kind of...

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  • November 13, 2024
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  • 2024/2025
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EmilyCharlene
NR511 Midterm Exam Study Guide
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Define diagnostic reasoning - ANSWER✔✔-Reflective thinking because the process

involves 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.




Seen as a kind of critical thinking.


What is subjective data? - ANSWER✔✔-Anything the patient tells you or complains of

regarding their symptoms




Chief complaint


HPI


ROS


What is objective data? - ANSWER✔✔-Anything YOU can see, touch, feel, hear, or

smell as part of your exam




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,Includes lab data, diagnostic test results, etc.


Identify components of HPI - ANSWER✔✔-Specifically related to the chief complaint

only




Detailed breakdown of CC




OLDCARTS


Describe the differences between medical billing and medical coding. - ANSWER✔✔-

Medical billing: 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




Medical coding: the use of codes to communicate with payers about which procedures

were performed and why.


Compare and contrast the two coding classification systems that are currently used in

the US healthcare system. - ANSWER✔✔-ICD: International classification of disease

codes are used to provide payer info on necessity of visit or procedure performed.

Shorthand for pt's dx.




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,CPT: common procedural terminology codes offer the official procedural coding rules

and guidelines required when reporting medical services and procedures performed by

physician and non-physician providers. Must have corresponding ICD.


How do specificity, sensitivity, and predictive value contribute to the usefulness of

diagnostic data? - ANSWER✔✔-Specificity: ability of a test to correctly detect a specific

condition. If a pt has a condition but test is negative, it is a false negative. If pt does

NOT have condition but test is positive, it is false positive.




Sensitivity: test that has few false negatives. Ability of a test to correctly identify a

specific condition when it is present. The higher the sensitivity, the lesser the likelihood

of a false negative.




Predictive value: The likelihood that the pt actually has the condition and is, in part,

dependent upon the prevalence of the condition in the population. If a condition is

highly likely, the positive result would be more accurate.




Diagnostic tests can be used to confirm or rule out hypotheses.




Diagnostic tests may be used to screen for conditions.

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, Diagnostic tests may be used to monitor the progress in managing a chronic condition.


Discuss the elements that need to be considered when developing a plan. -

ANSWER✔✔-Pt's preferences and actions


Research evidence


Clinical state/circumstances


Clinical expertise


Describe the components of medical decision making in E&M coding. - ANSWER✔✔-

Risk, data, diagnosis




The more time and consideration involved in dealing with a pt, the higher the

reimbursement from the payer.




Documentation must reflect MDM


Correctly order the E&M office visit codes based on complexity from least to most

complex. - ANSWER✔✔-New pt:


1. Minimal/RN visit: 99201


2. Problem focused: 99202
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