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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:
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, -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
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, -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
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, -Outpatient
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