NR511 Midterm Exam Study Guide

NR511 Midterm Exam Study Guide Week 1 1. Define diagnostic reasoning: type 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. Discuss and identify subjective & objective data  Subjective: what the patient reports; complaints of; tells you  Example: fevers, chills, lethargy, headache, blurred vision, ST, etc.  Is the “S” part of the SOAP note which includes the CC, HPI, & ROS  Objective: what you can see, hear, or feel as part of your clinical exam; also includes laboratory data and tests results  Example: thin, obese, normocephalic, rapid stress test +, etc.  Is the “O” part of the SOAP note 3. Discuss and identify the components of the HPI  Should be focused on the complaint and relevant symptoms  Detailed breakdown of the CC, written out as the OLDCARTS acronym  Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatments, Severity.  Duration: not referring to the onset of the symptom. Rather, it is an assessment of whether the symptom is constant or if it comes and goes.  Severity: level of pain, impact on work/school or ADLs. 4. 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, on the other hand, is 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. 5. Compare and contrast the 2 coding classification systems that are currently used in the US healthcare system  Common Procedural Terminology (CPT) system: offers the official procedural coding rules and guidelines required when reporting medical services and procedures performed by physician and nonphysician providers  Recognized universally and also provide a logical means to be able to track healthcare data, trends, and outcomes. Each service or procedure is represented by a five-digit code that is presented in six sections, including 1. Evaluation & Management 2 2. Anesthesiology 3. Surgery 4. Radiology 5. Pathology 6. Medicine  International Classification of Diseases (ICD) system: we are in the tenth revision of the system, and, therefore, the classification system is known as ICD-10  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. This means that every CPT code must have a diagnosis code that corresponds. 6. Discuss how specificity, sensitivity & predictive value contribute to the usefulness of the diagnostic data  When we describe the specificity of a test, we are referring to the ability of the test to correctly detect a specific condition. If the patient has the condition but testing is negative, we describe this as a false negative. If the patient does not have the condition but the test result is positive, this is considered to be a false positive test.  When a test is very sensitive, we mean it has few false negatives. The higher the sensitivity, the lesser the likelihood of a false negative. A sensitivity of 99% means that it is very unlikely for a false negative result.  Predictive value is the likelihood that the patient actually has the condition and is, in part, dependent upon the prevalence of the condition in the population. If a condition is highly likely, a positive test result is more likely to be accurate. If a condition is very unlikely, a positive test needs to be questioned and perhaps additional testing would need to be done.  5 things to consider before ordering a test: cost, convenience, sensitivity, specificity, risk of missing a condition (predictive value) 7. Discuss the elements that need to be considered when developing a plan  Evidence based care: providing care and making treatment and screening choices based on current research findings. Generally, EBP refers to using research findings from multiple studies that are convincing enough that a consensus is formed recommending the findings be used for clinical decision-making or practice guidelines.  EBP also involves inclusion of patient and provider preferences, patient values, and cultural considerations in the clinical decision-making process. Guidelines should be followed in the majority of cases unless there is a clear rationale for deviating from them to serve the particular needs of the patient.  Elements include clinical state and circumstances, patient’s preferences and actions, research evidence, and clinical expertise 8. Discuss a minimum of three purposes of the written history and physical in relation to the importance of documentation  It is an important reference document that gives concise information about a patient's history and exam findings. 3  It 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.  It is a means of communicating information to all providers who are involved in the care of a particular patient.  It is an important medical-legal document.  It is essential in order to accurately code and bill for services. 9. 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.  Understanding and accurately recording procedure and diagnosis codes are necessities in order for you or your practice to get reimbursed. 10. Correctly identify a patient as new or established given the historical information  A new patient is one who has not received professional service from a provider from the same group practice within the past 3 years. Conversely, an established patient has received professional service from a provider of your office within the last 3 years. 11. Identify the 3 components required in determining an outpatient, office visit E&M code  Place of service  Type of service  Patient status  3 components in determining the E&M code are Hx, PE, & Medical Decision Making 12. Describe the components of Medical Decision Making in E&M coding  Medical decision making is another way of quantifying the complexity of the thinking that is required for the visit.  Complexity of a visit is based on three criteria: risk, data, & diagnosis  MDM score gives us credit for the excess work involved in management of a more complex patient. 13. Correctly order the E&M office visit codes based on complexity from least to most complex New Established Minimal/RN visit Problem Focused Exp. Problem Focused 99203 99213 Detailed Comprehensive 14. Explain what a “well rounded” clinical experience means 4  Both state boards of nursing and the National Certification Exam bodies can ask to audit your clinical hours when you apply for testing and licensing. If they feel you don’t have a varied enough experience across the lifespan, they can refuse to allow you to sit for your exam or be licensed as a family nurse practitioner. (A rule of thumb for them is 15% of peds and 15% of women’s health exposure of total clinical time in a program.)  A true well-rounded experience will include both children from birth through young adult visits for well child and acute visits, as well as adults for wellness and acute or routine visits. 15. State the maximum number of hours that time can be spent “rounding” in a facility  Time spent is no more than 25% of total practicum hours for that course. 16. State 9 things that must be documented when inputting data into clinical encounter 1. Date of service 2. Age 3. Gender and ethnicity 4. Visit E&M code (e.g., 99203) 5. Chief concern 6. Procedures 7. Tests performed or ordered 8. Diagnoses 9. Level of involvement (mostly student, mostly preceptor, together, etc.). 17. Identify and explain each part of the acronym SNAPPS  Summarize: present your patient’s history and physical exam findings  Narrow: narrow your differential down to 2-3 differential diagnoses  Analyze: analyze the differential. Compare and contrast the history and physical exam findings for each of the differentials you have, ultimately coming down to one most likely diagnosis based on your data.  Probe: ask the preceptor questions about things that you aren’t quite sure about.  Plan: come up with a management plan, being as specific as possible.  Self-directed learning: investigate more about the topics you are unsure about. Week 2  Pain in abdomen relative to quadrants  LUQ: stomach ulcers, pancreatitis, and gastritis  RUQ: problems with gallbladder, hepatitis, or pancreatitis  RLQ: Inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), infectious colitis, and constipation  LLQ: diverticulitis, inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), constipation, and infectious colitis