NR511 MIDTERM QUESTIONS WITH COMPLETE
SOLUTIONS GUARANTEED PASS BRAND NEW 2025
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
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.
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.
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
3. Expanded problem focused: 99203
4. Detailed: 99204
5. Comprehensive: 99205
Established pt:
1. Minimal/RN visit: 99211
2. Problem focused: 99212
3. Expanded problem focused: 99213
4. Detailed: 99214
5. Comprehensive: 99215
The 5 key components of a comprehensive treatment plan are:
- ANSWER - >1. Diagnostics
2. Medication
3. Education
4. Referral/consultation
5. Follow-up planning
Define the components of a SOAP note. - ANSWER - >S:
subjective (what the pt tells you)
CC
HPI
PMH
Fam Hx
Social Hx
SOLUTIONS GUARANTEED PASS BRAND NEW 2025
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
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.
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.
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
3. Expanded problem focused: 99203
4. Detailed: 99204
5. Comprehensive: 99205
Established pt:
1. Minimal/RN visit: 99211
2. Problem focused: 99212
3. Expanded problem focused: 99213
4. Detailed: 99214
5. Comprehensive: 99215
The 5 key components of a comprehensive treatment plan are:
- ANSWER - >1. Diagnostics
2. Medication
3. Education
4. Referral/consultation
5. Follow-up planning
Define the components of a SOAP note. - ANSWER - >S:
subjective (what the pt tells you)
CC
HPI
PMH
Fam Hx
Social Hx
